Surgical methods in the treatment of congenital anomalies of the uterine cervix.

PURPOSE OF REVIEW: Cervical agenesis is an extremely rare congenital anomaly of the female reproductive tract. There are many anatomical forms that constitute this type of cervical abnormality and the literature is replete with attempts to surgically restore a patent outflow tract and preserve fertility in these patients. There are no carefully designed cohort or randomized trials to support a best surgical practice; past reports are descriptive only. RECENT FINDINGS: Of late, there has been renewed interest in the surgical treatment of cervical dysgenesis with techniques both through laparotomy with hysterotomy and more recently, minimally invasive approaches, which have attempted to restore a patent outflow tract without perineal dissection or graft harvesting in an attempt to avoid uterovaginal scarring if further surgery is necessary. To maintain consistency in the field of surgical reconstruction of the female reproductive tract, there has been a call for streamlined classifications of the anatomical abnormalities observed to better compare patient findings and the outcome of their surgical reconstruction in the literature. SUMMARY: The authors discuss the embryological development of this rare reproductive tract abnormality and have proposed a systematic surgical strategy for each anatomic finding. Ultimately, counseling patients on the best surgical approach requires a discussion on the potential postoperative complications, the degree of cervical abnormality, and the patient's desired treatment outcome. Whether the patient desires definitive treatment with a hysterectomy to avoid the risk of further surgery or, when anatomically appropriate, she wants to pursue a patent outflow tract and the possibility of future childbearing, evidence-based medicine must become the source for surgical strategies.

Congenital anomalies of the uterine cervix: lessons from 30 cases managed clinically by a common protocol.

OBJECTIVES: To outline the anatomic variations of malformations of the uterine cervix and to discuss the clinical management of cervical agenesis and dysgenesis. DESIGN: Thirty patients who were treated for cervical malformations in six institutions during a 69-year interval are reviewed. SETTING: Hospital-based tertiary-care reproductive endocrine infertility units. PATIENT(S): Thirty women with congenital uterine-cervical anomalies. INTERVENTION(S): Exploratory laparotomy with cervicovaginal reconstruction or hysterectomy. MAIN OUTCOME MEASURE(S): All surgical findings were carefully reviewed to determine the anatomic characteristics of the malformed cervix. When cervical reconstruction was performed, the patient was followed to determine the need for reoperation or if the patient achieved a pregnancy. RESULT(S): Patients lacked a cervix (cervical agenesis) or had one of three variants of cervical dysgenesis. Patients with cervical dysgenesis were characterized as having: 1) an intact cervical body with obstruction of the cervical os; 2) a cervical body consisting of a fibrous band or cord; or 3) cervical fragmentation. One patient conceived after reconstruction. Reoperation was less likely to occur among women who had an obstructed endocervical canal but an otherwise normal cervical body. CONCLUSION(S): There are two forms of anatomic congenital cervical malformations, the second of which may be considered as three distinct variations.

Applications of estradiol and testosterone assays in the management of the infertile female patient.

A collaborative effort to improve steroid hormone measurements in patient care was convened by the Centers for Disease Control in March 2008 to discuss the need for enhanced performance and standardization of clinical estradiol and testosterone assays. This article discusses the current status of estradiol and testosterone assays in the treatment of infertile women to include the assessment of ovarian reserve, ovulation induction and follicle tracking, ovarian hyperstimulation syndrome, and the role of testosterone in fertility management.

The current staging system for endometriosis: does it help?

A multicenter collaboration for data collection and statistical analysis may be necessary to establish and validate a classification system based on empirically derived scores for specific pathologic observations. The endometriosis pain instrument may be a tool for some of those variables with regard to pelvic pain. A similar strategy for uniform collection of data for analysis of important factors also is necessary for infertility. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome or aid in the management of pelvic pain is recognized to be inadequate. Further revisions of the current classification scheme are anticipated as the understanding of how endometriosis contributes to infertility and pelvic pain evolves. In any revision of the classification system, use of empirically derived weights and breakpoints to define disease stages based on outcome data in larger clinical trials should be attempted. It is also possible that additional factors, such as CA-125 level or lesion characteristics, may be shown to play an important role in prognosis. If so, these must be accounted for in the classification scheme. Careful and consistent use of the recommendations of the American Society for Reproductive Medicine classification of endometriosis subcommittee should allow for collection of data for use in further revisions. It is possible that a classification scheme that is designed to predict outcome with respect to pregnancy may be totally inadequate in assessing patients who have endometriosis and pelvic pain. Factors found to be important in the assessment of pelvic pain may be different from those involved with the pathophysiology of endometriosis and infertility. The AFS form suggested for use in the management of endometriosis in the presence of pelvic pain allows for recording of variables such as depth of invasion, histology, and documenting adjunct investigations and preoperative physical findings. Such prospective data collection and review in large centers may provide a large clinical base from which to derive empirical point scores and breakpoints in a classification scheme.

Differential effects of oral estrogen versus oral estrogen-androgen replacement therapy on body composition in postmenopausal women.

Menopause is associated with decreased lean body mass and increased fat due to aging and declining hormone secretion. Estrogens or estrogen-progestins have been used to alleviate vasomotor symptoms. However, estrogen-androgen (E/A) therapy is also used for vasomotor symptom relief and has been shown to increase lean body mass while decreasing fat mass. The objective of this 16-wk, double-blind, randomized, parallel group clinical trial was to compare esterified estrogen plus methyltestosterone (1.25 mg estrogen + 2.5 mg methyltestosterone/d; E/A group) vs. esterified estrogen alone (1.25 mg/d; E group) on body composition. Forty postmenopausal women (mean age, 57 yr) participated. Compared with estrogen treatment alone, women in the E/A group increased their total lean body mass and reduced their percentage fat for all body parts (P < 0.05). After E/A treatment, there were statistically significant increases in lean body mass by 1.232 kg [0.181 +/- 0.004, 0.81 +/- 0.057, and 0.24 +/- 0.009 kg in the upper body (P = 0.021), trunk (P = 0.001), and lower body (P = 0.047), respectively]. In the E group, the increase was 0.31 +/- 0.004, 0.021 +/- 0.03, and 0.056 +/- 0.05 kg in the upper body, trunk, and lower body, respectively. In the E/A group, body fat was reduced by 0.90 kg (P = 0.18 for the trunk only), and percentage body fat declined by 7.4% (P < or = 0.05 for all body parts). Lower body strength increased by 23.1 kg (51 lb) in the E/A group vs. only 11 kg (24.25 lb) in the E group (P = 0.002 between groups). A statistically significant increase in weight (2.7 +/- 5.1 vs. 0.1 +/- 4.6 lb; P < 0.05) was observed in the E/A group compared with the E group. When subjects were given self-reporting questionnaires, more improvement was noted in sexual functioning and quality of life in the E/A group when compared with patients receiving E alone. There were no noteworthy side effects. In conclusion, E/A replacement therapy can improve body composition, lower-body muscle strength, quality of life, and sexual functioning in postmenopausal women.