[Menometrorrhagia]. / Une prise en charge qui répond à un algorithme précis. Ménométrorragies.

Menometrorrhagia is a frequent cause of medical consulting. After exclusion of pregnancy, main aetiologies are the uterine (polyp, myoma, adenomyosis, cancer) or adnexial abnormality (ovarian cyst or cancer), the disorders of hemostasis (Willebrand...), the dysfunctional uterine bleeding. A clinical examination is necessary to provide an accurate diagnosis and find complications such as anaemia. Pelvic ultrasound examination and endometrial biopsy are required to eliminate endometrial cancer. The treatment of menometrorrhagia consists of symptomatic treatment (tranexamic acid, levonorgestrel intrauterine device) and specific treatment of its cause (hysteroscopic resection of myom, polyp, endometrectomy, hysterectomy).

Tuberculosis endometrial polyp.

Tuberculosis can cause infertility when it infects the genital tract (e.g., endometritis). A 31-year-old woman (origin: Algeria) was referred to our academic gynecological institute for unexplained primary infertility. The patient presented with no complaint. Hysteroscopy showed a 10 mm sized endometrial polyp. The polyp was removed. Pathology showed lymphocytic and plasmacytic chronic inflammatory modification, granulomatous modification, and gigantocellular modification,which lead to the diagnosis of tuberculosis. No acid fast organism was seen on Ziehl-Neelsen staining. A chest thorax X-ray revealed no sign of pulmonary tuberculosis. The patient underwent antituberculosis therapy during one year. Posttreatment hysteroscopy revealed no abnormality. This is the first reported case of endometrial tuberculosis diagnosed following removal of a polyp with classical benign appearance.

Metroplasty for AFS Class V and VI septate uterus in patients with infertility or miscarriage: reproductive outcomes study.

STUDY OBJECTIVE: To assess reproductive outcomes in patients after surgical correction of septate uterus. DESIGN: Observational retrospective study (Canadian Task Force classification II-2). SETTING: Two university hospitals. PATIENTS: One hundred twenty-eight patients with primary infertility or recurrent miscarriage with partial (American Fertility Society [AFS] class Va), complete (AFS class Vb), or fundic (AFS class VI) septate uterus. Metroplasty is the current method of choice for surgically correcting septate uterus. The procedure and its indications are a matter of debate. INTERVENTIONS: Metroplasty via hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Outcomes including the numbers of pregnancies, first live births (FLBs), and miscarriages were determined. After metroplasty, 78 women (60.9%) became pregnant, and 70 live neonates were delivered. The FLB rate in infertile women was 53.1%. Of the 25 pregnancies, 13 (52%) resulted from assisted reproductive technology. In women who experienced recurrent miscarriage, the miscarriage rate was significantly improved. Outcomes (miscarriages and FLBs) differed significantly according to anatomical type of septum after surgery. CONCLUSION: Hysteroscopic septum resection is accompanied by safe improvement in reproductive performance in patients with symptoms of AFS class V/VI septate uterus.

Total adhesions treated by hysteroscopy: must we stop at two procedures?

OBJECTIVE: To study the anatomic and fertility results after treatment for Asherman syndrome involving more than two separate surgical procedures. DESIGN: Retrospective case series. SETTING: Tertiary center. PATIENT(S): Twenty-three women who had Asherman syndrome and required more than two hysteroscopic operative procedures. INTERVENTION(S): Third or higher-order operative hysteroscopy procedure. MEAN OUTCOME MEASURE(S): Fertility rate. RESULT(S): The women's mean age was 34 years (± 5.8 years) when treatment for adhesions began. All women initially had adhesions classified as severe with total amenorrhea. Twelve patients had three separate procedures to treat the adhesions, nine had four treatments, and two had five treatments. One woman was lost to follow-up. At the conclusion of treatment, more than 80% of the women had either no adhesions at all or only mild adhesions. The overall pregnancy rate was 40.9%; there were nine pregnancies and six term infants (27.2%). All but one of these pregnancies were spontaneous. The mean time to pregnancy was 10.5 months (± 4.7 months). CONCLUSION(S): The number of hysteroscopic procedures envisioned to treat Asherman syndrome should not be a limiting factor. It is appropriate to treat women, especially those younger than 35 years, until uterine anatomy permits the visualization of both ostia.

Combined conservative surgical and medical treatment of a uterocutaneous fistula.

Uterocutaneous fistula is a rare complication that may follow cesarean section. Herein is described a rare case of uterocutaneous fistula. The patient, a 28-year-old woman with a history of American Society for Reproductive Medicine stage IV endometriosis (Douglas pouch obliteration), underwent a cesarean section at 25 weeks of gestation (twin pregnancy). Postoperatively, the patient returned to the emergency service because of the appearance of pus through the cesarean section abdominal scar, and was treated for a subcutaneous abscess. Because drainage continued, the presence of a uterocutaneous fistula was suspected. Magnetic resonance imaging confirmed this diagnosis. Hysteroscopy clearly revealed the uterine neck of the fistula tract. Leuprolide acetate (gonadotropin-releasing hormone agonist) deposit suspension was administered subcutaneously monthly for 6 months. Surgery via laparoscopy and laparotomy was performed. This combined medical and conservative surgical treatment was successful. At 6-month follow-up, hysteroscopy revealed a normal uterine cavity. We conclude that magnetic resonance imaging and hysteroscopy are helpful in diagnosis of uterocutaneous fistula. Conservative surgical treatment associated with medical therapy can be an efficient procedure in women who desire subsequent pregnancies.

Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging.

STUDY OBJECTIVE: To estimate the accuracy of 3-dimensional (3-D) ultrasonography in the differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging (MRI). DESIGN: Prospective cohort study (Canadian Task Force Classification II-2). SETTING: University hospital. PATIENTS: Thirty-one patients referred with a suspected diagnosis of septate (n = 20) or bicornuate (n = 11) uterus. INTERVENTIONS: All patients underwent 3-D ultrasonography displaying the rebuilt coronal view of the uterus, office hysteroscopy, and pelvic MRI. Operative hysteroscopic assessment and treatment was performed in case of sonographically diagnosed septate uterus. Bicornuate uterus was confirmed by laparoscopy. MAIN OUTCOMES MEASURES: Concordance between suspected diagnosis with 3-D ultrasonography, hysteroscopy, and pelvic MRI and final diagnosis. RESULTS: A septate uterus was diagnosed with 3-D ultrasonography in 29 patients and bicornuate uterus in 2 patients. Hysteroscopic transcervical section of the uterine septum was achieved in the 29 patients. Bicornuate uterus was laparoscopically confirmed in the 2 patients. Concordance between ultrasonography and operative hysteroscopy or laparoscopy was verified in all 31 cases. Twenty-five uterine septa and 5 bicornuate uteri were diagnosed by hysteroscopy (3 false-positive diagnoses of bicornuate uterus, 1 unfeasible hysteroscopy). Hysteroscopic diagnosis was correct in 27/30 patients. Twenty-four septate uteri and 7 bicornuate uteri were diagnosed by MRI (5 false-positive diagnoses of bicornuate uterus). Two complete septate uteri diagnosed by MRI were finally confirmed as incomplete septate uteri after 3-D ultrasonography and operative hysteroscopy. MRI diagnosis was correct in 24/31 patients. CONCLUSION: Transvaginal 3-D ultrasonography appears to be extremely accurate for the diagnosis and classification of congenital uterine anomalies, more than office hysteroscopy and MRI. It may conveniently become the only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus.

Treatment of twenty-two patients with complete uterine and vaginal septum.

STUDY OBJECTIVE: To assess the fertility and obstetric outcome after surgical treatment of complete uterine and vaginal septum. DESIGN: Retrospective study (Canadian Task Force Classification II-2). SETTING: Teaching hospital in France. PATIENTS: Twenty-two women who have experienced infertility, pregnancy losses, dyspareunia, or dysmenorrhea. INTERVENTION: Hysteroscopic section of complete uterine septum and resection of longitudinal vaginal septum. MEASUREMENTS AND MAIN RESULTS: Improvement of dyspareunia or dysmenorrhea and obstetric outcome, focusing on the miscarriage rate, obstetric complications, and the gestational age at delivery were assessed. Overall, 20 women had conceived a total of 37 pregnancies, with 10 and 8 deliveries before and after metroplasty, respectively. Median gestational age at delivery was not significantly different in both groups (36.5 [33-39.5] vs 38.0 weeks' gestation [35-40], respectively). Preterm delivery occurred in 4 cases (25%) before the surgery and in 3 cases (14%) after (p = .44). The live birth rate was also not significantly different before and after surgery (62.5% and 38%, respectively) (p = .19). There was a decrease of caesarean section and significantly fewer breech deliveries after metroplasty (p = .01). A decrease in the prevalence of dyspareunia or dysmenorrhea was observed after metroplasty in the 19 patients originally displaying these symptoms. No perioperative complications were observed in this series. CONCLUSION: Resection of vaginal septum and hysteroscopic metroplasty for complete uterine septum with resection of the cervical septum is a safe procedure that may improve dyspareunia and dysmenorrhea when present. Reproductive and obstetric outcomes after this procedure do not appear to be compromised, even though a relatively high miscarriage rate remains after metroplasty, questioning its systematic practice in symptom-free women without any previous obstetric history.

3D ultrasound to assess the position of tubal sterilization microinserts.

BACKGROUND: The aim of this study was to assess the diagnostic accuracy of three-dimensional ultrasound (3D-US) for determining the position of Essure microinserts and the success of sterilization by the Essure method. METHODS: This retrospective observational study examined the case records of 311 women who underwent hysteroscopic sterilization from October 2002 through October 2008. Imaging with 3D-US or pelvic X-radiography or both was performed 3 months after the procedure to verify device position. Hysterosalpingography (HSG) was performed when a bilateral procedure was not completed because of a history of salpingectomy or blocked tube, when doubt persisted after 3D-US or pelvic radiography, or for comparative purposes in a prospective study. The positions seen on 3D-US were classified in four categories according to a specific scale we devised. RESULTS: The insertion procedure was completed in 94.2% patients. Only 90.5% underwent imaging verification of the device 3 months afterwards. In all, 227 3D-US, 175 pelvic radiography and 64 HSG imaging procedures were performed. Visualization of the device was possible in 99.6% of the 3D-US images. According to our classification, 3D-US was appropriate for assessing device position for 195 (85.9%) patients. The need for HSG confirmation was significantly lower with 3D-US than radiographic imaging (14.1 versus 26.8%, P = 0.001). 3D-US examinations, compared with the results of HSG as the reference test, had a sensitivity of 100% and a specificity of 76.6%. Neither pregnancy nor early expulsion occurred when 3D-US found that the devices were correctly placed. CONCLUSIONS: 3D-US is a simple technique for assessing the position of Essure(®) microinserts, even after concomitant endometrial surgery. The 3D-US classification presented here appears to make it possible to use HSG for back-up confirmation only when the microinsert is found in a very distal position on 3D-US and thus to protect the majority of women from the negative effects of pelvic radiography and HSG.

Surgical reduction of hypertrophy of the labia minora.

OBJECTIVE: To evaluate postoperative satisfaction, including improvements in quality of life, among patients who had undergone labia minora reduction. METHODS: In a retrospective descriptive study, women who had undergone labiaplasty for hypertrophy of the labia minora between January 2005 and December 2009 were contacted by telephone. The women were asked to answer a satisfaction survey evaluating the esthetic and functional results of the surgery. RESULTS: Among 21 patients who had labiaplasty using either a pedicle flap reconstruction (n=18, 86%) or a nymphectomy technique (n=3, 14%), 18 (86%) were contacted successfully and took part in the survey. All of the contacted patients were satisfied with the overall outcome of the surgery, with a mean rating of 8.7 out of 10 at a median follow-up of 17 months (interquartile range 6-25 months). From an esthetic point of view, all 18 patients reported an improvement in comfort with respect to any form of original functional discomfort. Concerning sexuality, 95% of the sexually active patients had originally described some form of physical or psychologic discomfort, and all of them reported total disappearance of this symptomatology. CONCLUSION: Labiaplasty provided overall satisfaction in terms of improvements in patient quality of life and sexuality.

Surgical management of infertility due to polycystic ovarian syndrome after failure of medical management.

OBJECTIVES: To evaluate surgical management and fertility and pregnancy outcome in women with polycystic ovarian syndrome (PCOS). STUDY DESIGN: Retrospective file review and follow-up of 74 consecutive women with PCOS resistant to citrate clomiphene (CC) who underwent ovarian drilling by fertiloscopy with bipolar energy, together with hysteroscopic surgery when indicated (Canadian TASK FORCE II-2). RESULTS: Of 77 files, only 3 women were lost to follow-up. Mean age was 30.2 years (SD 5.3) [29.0-31.4 CI 95%], and mean BMI 25.6kg/m(2) (SD 6.2) [24.2-27.0 CI 95%]. Pregnancy occurred after drilling in 47 cases (63%), spontaneously in 20 (27%), after ovarian stimulation in 5 (6.7%) and after in vitro fertilization in 22 (29.7%). Laparoscopic conversion was required in 5 cases (6.7%), due to failure to visualize the adnexa (n=3), or pelvic adhesions (n=1), or uterine hemorrhage (n=1). Hysteroscopy detected and simultaneously treated a uterine anomaly in 18 of 74 patients: uterine septum (n=10, 13%), T-shaped uterine cavity (n=3, 4%), endometrial polyp (n=2, 2.7%), endometrial hypertrophy (n=2, 2.7%), and synechiae (n=1, 1.3%). The mean overall delay to pregnancy was 11.1 months (SD 8.5) [8.7-13.5 CI 95%] and to spontaneous pregnancy, 7 months (SD 7.6) [3.7-10.3 CI 95%]. The mean follow-up was 23.4 months (SD 16.5) [18.1-28.7 CI 95%]. After multivariate analysis, the likelihood of pregnancy was significantly associated with previous ovarian stimulation by FSH (OR=2.28, 95% CI=1.08-4.83) and initial FSH level (OR=0.52, 95% CI=0.29-0.93). CONCLUSION: Ovarian drilling by hydrolaparoscopy is an effective treatment for CC-resistant PCOS. The high rate of associated uterine anomalies justifies simultaneous hysteroscopic surgery.

Transvaginal cervicoisthmic cerclage using a polypropylene sling: pregnancy outcome.

AIM: To report pregnancy outcome following prophylactic transvaginal cervicoisthmic cerclage using a polypropylene sling in a population of high-risk pregnant women. MATERIALS AND METHODS: A retrospective study with a continuous series of 57 women presenting with prior failure of McDonald cerclage (n = 47) and/or absent portio-vaginalis of the cervix (n = 10). RESULTS: Cervicoisthmic cerclage was performed between 12 and 16 weeks of gestation (median 14 weeks' gestation). No intraoperative complication occurred. Preterm labor treated with parenteral tocolysis occurred in 14 women (24%). Cesarean delivery was systematically performed. Median gestational age at delivery was 37.2 weeks' gestation (interquartile range: 36.5-38.0). Overall neonatal survival rate was 94%. CONCLUSION: Transvaginal cervicoisthmic cerclage using a polypropylene sling may be considered as an effective alternative to the transabdominal cervicoisthmic cerclage in women presenting with previous cerclage failure.

Ovarian drilling for surgical treatment of polycystic ovarian syndrome: a comprehensive review.

This systematic literature review is intended to clarify and evaluate the results obtained by ovarian drilling as surgical treatment for polycystic ovarian syndrome (PCOS). Four databases were consulted (Medline at the National Library of Medicine, USA; Cochrane Library, UK; National Guideline Clearinghouse, USA; and the Health Technology Assessment Database, Sweden) and searched for 'polycystic ovary syndrome' plus 'drilling' in the title or abstract. The assessment criteria used to define the efficacy of the procedure were the rates of ovulation, clinical pregnancy and early miscarriage. Alternatives to surgical ovarian drilling were evaluated. This search produced 147 references, 81 of which met the selection criteria. This review of infertility management in women with PCOS indicates that ovarian drilling is a second-line treatment when treatment with clomiphene citrate fails to lead to conception. The benefits of ovarian drilling are that it does not induce either hyperstimulation syndrome or multiple pregnancies. It is concluded that ovarian drilling is an option in the management of female infertility associated with PCOS, especially as a second-line treatment after the failure of clomiphene citrate treatment.

Tubal anastomosis after tubal sterilization: a review.

PURPOSE: To evaluate various techniques for restoring tubal patency after sterilisation. METHODS: A search strategy was designed, and for each subject either thesaurus terms (MeSH descriptors) or terms from the title or summary were used. RESULTS: Mean length of hospital stay following laparoscopy seems to be shorter in comparison with laparotomy (3.3 vs. 6.1 days, P < 0.05). Rate of conversion to laparotomy is 5%. Pregnancy rates observed are between 54 and 88% for laparotomy and 31-85% for laparoscopy. Mean time to conception was between 2 and 9.6 months. Most pregnancies occurred in the 2 years following restoration of tubal patency (cumulative conception rate 80% at 12 months). Young age (<35 years), type of ligature (rings), how recently the ligature was done (<8 years), the anastomosis site (in the middle of the tube) and a good length of remaining tube (>7 cm) are the factors that govern whether there can be good restoration of tubal patency. Ectopic pregnancy rates observed are between 1.7 and 12% for laparotomy and 0-7% for laparoscopy. There are no randomised or quasi-randomised studies comparing tubal anastomosis and in vitro fertilization. CONCLUSIONS: There are few good-quality controlled studies in this area. Results of restoration of tubal patency seem to be comparable, regardless of the route of approach (laparotomy or laparoscopy).

Assessment of three-dimensional ultrasound examination classification to check the position of the tubal sterilization microinsert.

OBJECTIVE: To assess the accuracy of three-dimensional (3D) ultrasound to determine the position of Essure microinserts. DESIGN: Prospective observational study. SETTING: Gynecology department in a teaching hospital. PATIENT(S): Forty women who underwent hysteroscopic sterilization from March through October 2008. INTERVENTION(S): Both 3D ultrasound and hysterosalpingography (HSG) were performed 3 months after the procedure to verify device position. Positions seen on 3D ultrasound were classified in four categories: a perfect position (1 + 2 + 3), a proximal position (1 + 2), a distal position (2 + 3), and a very distal position (3-only). MAIN OUTCOME AND MEASURE(S): Microinsert position on 3D ultrasound and correlation with HSG. RESULT(S): Overall, 93% of the devices for 40 patients were found to have been placed successfully. The final sample comprised 64 Essure devices. HSG showed tubal patency for only three devices, all classified as 3-only. No tubal permeability was noted for the other 61 positions. This 3-only location on 3D ultrasound was statistically associated with a failure of sterilization in comparison with the other locations (3/16 [18%] vs. 0/48 [0%]). CONCLUSION(S): 3D ultrasound is a simple and reproducible technique to assess the position of the Essure microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. Using the 3D ultrasound classification presented in this study appears to make it possible to use HSG for backup confirmation only when Essure is found to be in the 3-only position on 3D ultrasound.

Vaginal myomectomy: literature review.

The objective of this literature review was to evaluate the results obtained at vaginal myomectomy. The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse, and Health Technology Assessment Database. Keywords used for research were colpotomy, myomectomy, and vaginal myomectomy, and then abdominal myomectomy, laparoscopic-assisted vaginal myomectomy, and laparoscopic myomectomy. Eight case series and 2 case reports were analyzed, and included 372 patients. Reported rates of conversion to laparotomy during the operation ranged from 0% to 17.6%. The most frequently described risk factors for conversion to laparotomy were location of the myoma in the fundus and a large volume of myoma to be extracted, although no maximum threshold size can be defined. Performing laparoscopy first does not seem to limit the risk. Reported rates of transfusion during the operation ranged from 0% to 40%. Several cases of pelvic abscess have been described, with reported frequency of 2.2% to 5.7%. Authors mentioned the role of the vaginal drain that is inserted at the end of the procedure. No specific studies have been performed on long-term effectiveness, postoperative adhesions, integrity of the scar, or subsequent fertility. There are no good controlled studies of this technique. Feasibility seems to be acceptable, although the risk of pelvic infection in the postoperative period may be increased. Long-term effectiveness and safety were not assessed. A vaginal approach may be considered an alternative to laparotomy or laparoscopy in surgery to treat accessible myomas, and seems to be the simplest method.

Fertility outcome following transvaginal cervicoisthmic cerclage using a polypropylene sling.

OBJECTIVE: To report fertility and pregnancy outcomes following transvaginal cervicoisthmic cerclage with a polypropylene sling during a previous pregnancy. METHODS: A continuous series of 57 women who underwent prophylactic cervicoisthmic cerclage during a previous (reference) pregnancy were enrolled. Telephone interviews were carried out to evaluate each patient's subsequent fertility. RESULTS: Among the 57 women interviewed, 8 had an inadequate follow-up, 13 women were lost to follow-up, 1 woman required a hemostatic hysterectomy, and 2 women required removal of the sling. Nineteen women did not desire a subsequent pregnancy. Of the 14 women who did desire a subsequent pregnancy, 1 woman had previously known tubal infertility. Of the 13 remaining women, 7 subsequently became pregnant. One woman had a spontaneous abortion (11 weeks of pregnancy); 1 woman delivered at 22 weeks of pregnancy, after a spontaneous premature membrane rupture; 1 woman had a cesarean delivery at 25 weeks of pregnancy; and 4 patients had a cesarean delivery after 37 weeks of pregnancy. Median duration of the 4 subsequent pregnancies at delivery was 37 weeks (interquartile range [IQR], 37-38 weeks). Median birth weight was 3040 g (IQR, 2500-3250 g). CONCLUSION: Subsequent pregnancy is possible after transvaginal cervicoisthmic cerclage using a synthetic sling.

Laparoscopic ovarian drilling using a 5-French bipolar energy probe.

OBJECTIVE: To report a new technique of laparoscopic ovarian drilling using a 5-Fr bipolar electrode. DESIGN: Retrospective study (case series). SETTING: University hospital. PATIENT(S): Patients presenting with polycystic ovarian syndrome. INTERVENTION(S): Laparoscopic ovarian drilling using a 5-Fr bipolar probe. MAIN OUTCOME MEASURE(S): Feasibility of operative technique. RESULT(S): No perioperative complication was noted. CONCLUSION(S): We describe a new technique of laparoscopic ovarian drilling using a bipolar electrosurgical probe.

Hysteroscopic management of residual trophoblastic tissue and reproductive outcome: a pilot study.

We report on the feasibility, efficiency, and reproductive outcomes of hysteroscopic resection of late residual trophoblastic tissue in 50 patients in an observational study over 6 years. Complete evacuation of the uterus was achieved in all patients by hysteroscopy. The median operative time was 21 (15-30) min. Only one surgical complication was registered: a uterine perforation in a patient with previous metroplasty. Hysteroscopic resection of persistent trophoblastic tissue seems to be a safe and efficient procedure that could be proposed as an alternative to conventional non-selective blind curettage. We would also recommend systematic second-look hysteroscopy to asess the exact prevalence of post-procedure intrauterine adhesions.