Monophasic estrogen-progestogen therapy and sexuality in postmenopausal women.

OBJECTIVE: This study aimed to evaluate the effects of monophasic estrogen-progestogen therapy on the sexuality and climacteric symptoms of postmenopausal women. PATIENTS AND METHODS: A prospective, randomised, double-blind, crossover, placebo-controlled, single-centre study was carried out over a total of 12 consecutive months in 40 postmenopausal women with an intact uterus who had no contraindications to hormone therapy. Patients received 17beta-estradiol 2mg in combination with norethisterone acetate 1mg (Cliane) daily for 6 months or one placebo tablet daily for 6 months. The tablets were identical in appearance. After 6 months, the groups were crossed over and the patients were followed up for another 6 months. The groups were homogenous with respect to age, height, bodyweight, body mass index and race. For the statistical analysis, the group receiving hormone therapy was referred to as group A and the placebo group was designated group B, irrespective of the placebo/hormone therapy sequence. RESULTS: In group A there were fewer hot flashes (F=22.85, p<0.01) and an improvement in sexual interest (F=5.55, p<0.05). The sequence in which the medication was received resulted in a statistically significant difference with respect to dyspareunia (F=9.65, p<0.01) and satisfaction with the duration of penetration (F=6.58, p<0.05). In the intrapatient analysis of variation with respect to orgasmic capability and the presence of dialogue with partner regarding the couple's sexual life, whether the placebo was taken prior to or following hormone therapy was significant (F=17.12, p<0.001 and F=7.10, p<0.05, respectively). CONCLUSIONS: Monophasic estrogen-progestogen therapy has a beneficial effect on sexuality and on hot flashes in postmenopausal women.

Effects of conjugated equine estrogens or raloxifene on lipid profile, coagulation and fibrinolysis factors in postmenopausal women.

OBJECTIVES: To compare the effect of conjugated equine estrogens (CEE) and raloxifene on lipid profile and hemostasis. MATERIALS AND METHODS: A double-blind, randomized and parallel study was performed with 90 healthy postmenopausal women, aged 54 +/- 5 years, divided into three groups and submitted to daily therapy with either CEE 0.625 mg, raloxifene 60 mg or placebo for 4 months. The lipid profile, coagulation and fibrinolytic factors were analyzed. RESULTS: CEE increased the levels of high density lipoprotein cholesterol (HDL-C) from 49.0 to 56.8 mg/dl (p < 0.001), very low density lipoprotein cholesterol (VLDL-C) from 17.2 to 22.3 mg/dl (p < 0.001), and triglycerides from 86.0 to 111.7 mg/dl (p < 0.001), and decreased the levels of low density lipoprotein cholesterol (LDL-C) from 121.0 to 106.5 mg/dl (p < 0.001). The only significant effect of raloxifene was an increase in the levels of HDL-C from 46.0 to 47.8 mg/dl (p = 0.019). There was no significant reduction in LDL-C, from 115.5 to 110.2 mg/dl (p = 0.06), VLDL-C, from 21.7 to 20.0 mg/dl (p = 0.201), and triglycerides, from 108 to 100 mg/dl (p = 0.201). CEE decreased the levels of fibrinogen, from 370.5 to 326.8 g/l (p = 0.039) and the levels of antithrombin III, from 99.5 to 93.2% (p < 0.001). Raloxifene decreased the levels of fibrinogen, from 354.7 to 302.0 g/l (p = 0.009) and the levels of antithrombin III, from 102.4 to 98.5% (p = 0.039). CEE increased levels of protein C from 103.7 to 115.3 mg/l (p < 0.001) and raloxifene did not change the levels of protein C (107.9 to 105.1 mg/l; p = 0.158). CEE decreased the antigen levels of tissue plasminogen activator (t-PA) from 8.8 to 6.8 U/ml (p < 0.001), and of plasminogen activator inhibitor (PAI-1) from 30.8 to 21.6 U/ml (p < 0.010), whereas raloxifene had no significant effect on either t-PA, from 9.6 to 9.2 U/ml (p = 0.235) or PAI-1 antigen levels, from 32.1 to 30.4 U/ml (p = 0.538). CONCLUSION Both CEE and raloxifene exert significant effects on the lipid and coagulation profile. CEE had a more significant effect on fibrinolysis than raloxifene. These effects may have a significant impact on the cardiovascular risk that needs to be confirmed in larger studies.

Laparoscopic tubal anastomosis.

OBJECTIVES: To evaluate the pregnancy outcome after laparoscopic tubal anastomosis. METHODS: From December 1998 to December 2001, 26 patients with bilateral tubal ligation who underwent laparoscopic tubal anastomosis were prospectively evaluated. Patients' age varied from 28 to 37 years. RESULTS: Laparoscopic tubal reversal was performed in 23 patients. Bilateral reversal was possible in all but two patients. The operation time ranged from 95 to 155 min and all patients were discharged in the following morning after surgery. After 3 months, tubal patency was confirmed in 15 patients (15/23). Pregnancy rate was 56.5% (13/23), without ectopic pregnancies. The average time from tubal reversal and pregnancy was 6 months. CONCLUSIONS: In selected cases, laparoscopic tubal reversal can be offered to patients who had been submitted to tubal sterilization and desire new pregnancies. Patient selection as well as meticulous surgical technique are key factors in achieving satisfactory pregnancy rates.

HPV prevalence among partners of women with cervical intraepithelial neoplasia.

OBJECTIVES: The objective of this study was to find HPV DNA incidence in women with CIN and normal women and in their respective partners, as well as the relation between the virus groups found in women with CIN or normal women and in their respective partners. METHODS: Partners of 30 women with CIN at several grades and of 60 normal women were prospectively assessed. In men, HPV search was performed by collecting samples through penile scraping for Hybrid Capture, followed by peniscopic evaluation and biopsy of acetowhite lesions. RESULTS: The presence of HPV DNA in male partners does not necessarily implicate the presence of HPV or even CIN in their female partners. CONCLUSIONS: If these results are confirmed by other authors, obtaining a peniscopy, a penile biopsy, and a HPV DNA search in partners that present with no clinical lesions, but in couples with women having CIN, would not be warranted.

A randomized study of total abdominal, vaginal and laparoscopic hysterectomy.

OBJECTIVES: To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy. METHODS: Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin-6 dosages) were compared by using Kruskal-Wallis, Dunn non-parametric test and variance analysis with repeated measurements. RESULTS: Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin-6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy. CONCLUSIONS: Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.

Histological classification of endometriosis as a predictor of response to treatment.

OBJECTIVES: To evaluate the usefulness of the histological classification of endometriosis in predicting responses to treatment. METHODS: We evaluated 412 biopsy specimens from 241 patients with pelvic endometriosis. Pain and infertility were evaluated before surgery. Disease location and stage of development were analyzed according to the 1985 American Society of Reproductive Medicine (ASRM) classification. Histological findings were classified as stromal, well-differentiated, undifferentiated, and mixed endometriosis. Clinical response to pain or infertility was evaluated. RESULTS: Histological findings, disease location and stage of development, and response to treatment were compared. Undifferentiated endometriosis was more frequently associated with stages III/IV than the well-differentiated and stromal histological types. Pure or mixed undifferentiated patterns were more frequently associated with rectovaginal endometriosis. When considering pain symptoms, patients presenting well-differentiated or stromal histological patterns responded better to therapeutic treatment than those who presented undifferentiated histological patterns. There were no significant differences in cases related to sterility. CONCLUSIONS: The histological categorization of endometriosis can help predict the behavioral patterns of the disease.

Primary chemotherapy effect in sentinel node detection in breast cancer.

PURPOSE: Sentinel node (SN) biopsy is a reliable method for improved staging of breast cancer, offering an alternative to routine axillary dissection. Perhaps preoperative chemotherapy could increase the rate of false-negative SN because of induced lymphatic changes. The aim of the study was to evaluate the utility of lymphoscintigraphy and of hand-held probe detection in the SN approach after chemotherapy, correlating it with histologic analysis of the axilla. METHODS: Eighty-three patients (mean age, 53 years; TNM stage I) were studied prospectively. They were separated into two groups: group 1 (G1), 37 patients with preoperative chemotherapy and group 2 (G2), 46 patients without chemotherapy. Mean tumor size was 2 cm in both groups. Lymphoscintigraphy was performed 3 to 4 hours after peritumoral injection of Tc-99m dextran-70 in a 0.2-ml volume and activity of 14.8 MBq (0.4 mCi), performed under ultrasound or mammographic control. On the following day, each patient underwent tumor resection with axillary dissection, included the SN. RESULTS: The SN was detected by scintigraphy in 78 patients (94%). The failure of SN to predict the axillary histologic status was significantly higher (P = 0.01) in G1 than in G2 (7 and 1 false-negative result, respectively). CONCLUSION: Preoperative chemotherapy seems to impair axillary evaluation by SN biopsy and should be used cautiously in this subset of patients.

Breast cancer metastatic to uterine leiomyosarcoma. A case report and review of the literature.

An unusual case of breast cancer metastatic to leiomyosarcoma of the uterus is reported. The patient had multiple metastases from the breast carcinoma and presented a pelvic mass in its evolution. A laparotomy with total hysterectomy and bilateral oophorectomy was performed to give pain relief. A review of the world literature about these uncommon sites of breast metastases is presented.

Sexuality in healthy postmenopausal women.

OBJECTIVE: To assess the influence of psychosocial factors, behavior and hormones on postmenopausal sexuality. METHODS: Nine hundred and ninety-nine women (age range 41-60 years) underwent physical and supplementary tests and answered questionnaires regarding sexual behavior. Sixty healthy women with 1 or more years of amenorrhea, without hormone replacement therapy and with a partner capable of intercourse were chosen from this group. Logistic regression models with dependent variables (sexual satisfaction and orgasmic capacity) and independent variables (sexual initiation, psychosocial factors, behavior, relationship, menopause and hormones) were developed. RESULTS: Important variables for sexual satisfaction were: good self-esteem (p< 0.01), first orgasm obtained by masturbation (p = 0.004), major personal income (p = 0.007), sexual initiation in adulthood (p = 0.008), value physical contact with partner (p = 0.021) and major orgasmic capacity p = 0.040). The following contributed (towards orgasmic capacity with the partner: sexual initiation in adulthood (p = 0.012), regular physical activity (p = 0.040) and higher testosterone levels (p = 0.050). CONCLUSIONS: The importance of relationship, psychological, hormonal, economic and behavioral factors confirm the complexity of sexuality, and we note that current as well as prior events seem to affect the sexual satisfaction and orgasmic capacity of healthy postmenopausal women.

Uterine artery embolization for the treatment of uterine leiomyomata.

OBJECTIVES: To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids. METHODS: Twenty-six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow-up was performed before the procedure, at 3 months, and 1 year after. RESULTS: All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm(3), after 3 months 255 cm(3) and after 1 year 202 cm(3). The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow-up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients). CONCLUSIONS: UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Therapy of uncomplicated urinary tract infections.

This article deals with many options in utilizing drugs commonly used in the therapy of uncomplicated urinary tract infections (UTIs), their doses and recommended durations of treatment. In addition, it discusses general and specific accompanying measures related to the decrease in prevalence, relapses and recurrences of UTIs, including some of the factors involved in patient adherence or discontinuation of drug regimens.

Urinary tract infections in women.

Urinary tract infection (UTI) is one of the most frequent diseases in medical practice. Some definitions and epidemiology of UTI and bacteriuria are discussed, as well as host susceptibility and defense mechanisms. Aspects of infection in young women and in the elderly are reported, emphasizing microbiological, clinical and therapeutic aspects. Finally, epidemiologic and clinical aspects of fungal UTI are discussed.

Urinary tract infections in pregnant women.

Urinary tract infections are of great importance during pregnancy owing to undesirable complications such as fetal and maternal morbidity. This paper describes the functional alterations that occur in this condition and predispose to infection. Clinical presentation and subsidiary diagnosis are discussed, including asymptomatic bacteriuria, cystitis and pyelonephritis. In addition, the authors report drug options, and their safety and duration of treatment during pregnancy.

Intraoperative pathological monitorization of surgical margins: a method to reduce recurrences after conservative treatment for breast cancer.

INTRODUCTION: Local recurrences after conservative surgical treatment for breast cancer are not uncommon and cause negative influences on the oncological prognosis and quality of life of the patients. Aiming to avoid this problem, we have developed a method of intraoperative pathological monitoring of surgical margins (IPMSM), in order to assure adequacy of resection. MATERIALS AND METHODS: IPMSM is based on radiological. macroscopic, cytological and histological examination of frozen sections of the breast specimens in the operating room during the surgery. We evaluated 98 women with 100 tumors clinical stage I-II breast cancer for whom we planned conservative surgery. The margins were oriented by the surgeon and inked by the pathologist in different colors to retain orientation. RESULTS AND DISCUSSSION: According to the histological or cytological results, immediate re-excision was indicated and performed in 40 (40.8%) cases. In six of these, we had to perform a mastectomy. The indications for additional resections were: insufficient margins in 23 cases, extensive intraductal component in eight, multifocality in four, atypical proliferative lesion at the margin in four and diffuse tumor in one. Permanent histological sections confirmed all intraoperative results. These patients were followed by a median period of 42 months (range 3 to 99 months) and we observed 1% of local recurrence and 5.1% of distant metastasis. We compared this group of patients with a control group represented by 149 cases of breast cancer stages I-II treated by conservative surgery, but not submitted to IPMSM. In the control group, we observed 17 (11.4%) local recurrences and 49 (32.9%) distant metastases after a follow-up period from 14 to 213 months (median of 126 months). CONCLUSION: The IPMSM proved to be a safe and accurate method to prevent additional surgery for insufficient margins and to reduce the recurrence rate.

Colpocitologia em ambulatório de ginecologia preventiva / Colpocytology in a preventive gynecological ambulatory

OBJETIVOS: Avaliar os resultados de colpocitologia oncótica de mulheres atendidas em ambulatório de ginecologia preventiva (Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo). MÉTODOS: Foram estudadas 6821 mulheres submetidas a exame clínico e ginecológico com realizaçäo de colpocitologia oncótica pela técnica de Papanicolaou. Estas mulheres foram consideradas conforme a faixa etária em três grupos: abaixo de 40 anos, entre 41 e 60 anos e acima de 60 anos. RESULTADOS: Amaioria das mulheres reconhecem tanto a necessidade da colpocitologia como sua periodicidade, principalmente entre as mais jovens. As mulheres acima de 60 anos eram as que mais referiam (54,1 por cento) näo conhecer a necessidade da colpocitologia oncótica, nem sua periodicidade (58,8 por cento); o grupo que melhor referia conhecimento da necessidade e periodicidade da colpocitologia oncótica foi o de mulheres entre 40 e 60 anos. O material foi considerado insuficiente para análise em 15,1 por cento ou inadequado em 1,1 por cento, sendo os resultados: classe I (21,7 por cento), II (59,9 por cento), III (2,0 por cento), IV (0,1 por cento) e V (0,1 por cento). Näo houve diferença significativa em relaçäo à distribuiçäo dos casos de neoplasia intraepitelial (NIC) entre as faixas etárias. O achado microbiológico mais freqüente foi Gardnerella sp. (8,6 por cento). Presença de papilomavírus humano (HPV) foi significativamente menor nas mulheres acima de 60 anos. CONCLUSÖES: O diagnóstico de alteraçöes colpocitológicas relacionadas a neoplasias foi de 2,2 por cento com detecçäo de Gardnerella sp. como o agente microbiológico mais prevalente por este método. A distribuiçäo de infecçäo pelo HPV mostrou declínio com o aumento da faixa etária. As mulheres mais velhas foram as que menos apresentavam conhecimento sobre a realizaçäo de colpocitologia

Microlaparoscopy in gynecology: analysis of 16 cases and review of literature.

Microlaparoscopy represents the development of endoscopic surgery towards a minimally invasive surgical procedure. The advantages include fewer surgical complications, faster return to daily activities, more comfortable postoperative recovery, and satisfactory aesthetic results. The possibility of performing surgery under sedation may result in shorter hospitalization, lower hospital costs, and easier anesthetic procedures. The authors report their preliminary experience with the use of microlaparoscopy, using optics and 2mm instruments, as well as a review of the literature since the introduction of this new technique. The report of these 16 cases demonstrates that microlaparoscopy is a feasible technique with satisfactory results. On the other hand, this new technique requires precise indications and a training period for the development of the skills necessary for performing these surgeries.

Uptake of a cholesterol-rich emulsion by neoplastic ovarian tissues.

OBJECTIVE: Previously, it was shown that a lipidic emulsion (LDE) composed of phospholipids and cholesterol esters which binds to low-density lipoprotein (LDL) receptors may concentrate in acute myeloid leukemia cells. In this study, we aimed to verify whether LDE also has the ability to concentrate in malignant ovarian cancer after being injected into the blood circulation of the patients. METHODS: Three groups of women scheduled for surgery were included in the survey: 13 bearing malignant tumors, 9 with benign ovarian tumors, and 13 without ovarian tumor who were scheduled to undergo oophorectomy due to malignant disease of the uterine cervix or endometrium. On the day prior to surgery they were injected with LDE labeled with [(14)C]cholesteryl oleate. Specimens of tumors and normal ovaries excised during surgery were lipid extracted and analyzed for radioactivity counting. Results were expressed in radioactive count (cpm) per gram of tissue. RESULTS: The mean of the uptakes of the emulsion radioactivity by the malignant tumors was roughly eightfold greater when compared with that of the contralateral normal ovaries (2261 +/- 1444 and 275 +/- 137 cpm/g, respectively, P < 0.012), benign tumors, and normal ovaries of the patients without ovarian tumors. CONCLUSION: LDE has the ability to concentrate in malignant ovarian tumor tissue. Therefore, it can be used as a vehicle to direct cytotoxic drugs against malignant ovarian tumors, thus diminishing the side effects of chemotherapy.

The insulin-like growth factor-I system and hormone replacement therapy.

OBJECTIVE: To determine the effects of hormone replacement therapy on plasma concentrations of free and total insulin-like growth factor (IGF)-I, IGF binding protein (BP)-1, and IGFBP-3. DESIGN: Clinical study. SETTING: Gynecologic clinic at a university hospital. PATIENT(S): Seventy-one postmenopausal women. INTERVENTION(S): Six cycles of four different hormonal replacement therapy regimens: oral conjugated estrogens, transdermal estradiol, oral conjugated estrogens and norethisterone, and transdermal estradiol and norethisterone acetate. MAIN OUTCOME MEASURE(S): Blood samples were collected before and after treatment for measurement of free and total IGF-I, IGFBP-1, and IGFBP-3. RESULT(S): Conjugated estrogen replacement therapy is associated with a decrease in plasma concentration of total IGF-I and increase in concentrations of free IGF-I and IGFBP-1. Transdermal estrogens have no effect on total and free IGF-I and IGFBP-1 concentrations. Oral norethisterone plus conjugated estrogens increased free IGF-I and IGFBP-1 concentrations but did not change IGF-I concentrations. Transdermal conjugated estrogens plus norethisterone acetate increased free IGF-I concentrations but not total IGF-I or IGFBP-1 concentrations. The plasma concentration of IGFBP-3 did not change in any group. CONCLUSION(S): Alterations in total IGF-I concentration can occur depending on the route of hormone replacement therapy administration. Free IGF-I concentrations were elevated in all study groups except that treated with transdermal estrogens.