The vascular cast of the human uterus: from anatomy to physiology.

The blood supply to the uterus originates mainly from the uterine artery. However, the uterine and ovarian arteries form anastomoses bilaterally. Controversy exists about the direction of the flow in the anastomoses and thus the origin of the arterial supply to the tube and tubal part of the uterus. A similar arcade is formed by the vaginal and uterine arteries. We have investigated the vascular border of supply between the uterine and ovarian arteries in postmenopausal women, which was positioned in the uterus 1-2 cm from the tube. A similar result was found in younger, ovulating women. However, the border between the territories irrigated by the uterine and ovarian arteries differs between the follicular and luteal phase; more uterine tissue is perfused from the ovarian artery when a large follicle is present. This constitutes the first description of a functionally determined shift in the territorial divide of two vascular systems and has numerous practical implications. The venous system copies the arterial one with one major exception: some of the uterine veins join the ovarian outlet. The close contact between veins and arteries facilitates transfer of substances, thus forming semilocal systems of regulation; for example, the ovary locally influences the function of the ipsilateral tube and part of the uterus. From a therapeutic point of view, it has been documented that application of progesterone to the vagina creates high uterine concentrations due to local vascular transfer.

Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases.

OBJECTIVE: To assess the reliability, feasibility, and safety of lens-based minihysteroscopy. DESIGN: Retrospective comparative study. SETTING: Academic research environment. PATIENT(S): Women with different indications for hysteroscopy. INTERVENTION(S): Six thousand seventeen outpatient diagnostic hysteroscopies with a minihysteroscope (2.7-mm outer diameter [OD] telescope with 3.5-mm OD single-flow diagnostic sheath) and 4,204 with traditional hysteroscope (4-mm OD telescope with 5-mm OD single-flow diagnostic sheath). All hysteroscopies were performed using a vaginoscopic approach and saline to distend the uterus. MAIN OUTCOME MEASURE(S): Rate of successful introduction of the hysteroscope, rate of satisfactory examinations, pain intensity experienced using an arbitrary pain scale (0 = no pain; 1 = low pain; 2 = moderate pain; 3 = severe pain), and number of side effects and complications. RESULT(S): In the minihysteroscopy, group rates of successful introduction and satisfactory examinations were significantly higher than in the traditional hysteroscope group (99.52% vs.72.53% and 98.53% vs. 92.33%, respectively), while pain and vagal reactions were significantly lower (0.10 +/- 0.34 vs.1.09 +/- 0.53 and 2.25% vs.17.12%, respectively). CONCLUSION(S): Hysteroscopy with lens-based minihysteroscopes was easier, less painful, more reliable, and safer than with 5-mm hysteroscopes. Minihysteroscopy with a vaginoscopic approach is a very well tolerated, effective, and safe outpatient procedure.

Placement of the vaginal 17beta-estradiol tablets in the inner or outer one third of the vagina affects the preferential delivery of 17beta-estradiol toward the uterus or periurethral areas, thereby modifying efficacy and endometrial safety.

OBJECTIVE: The purpose of this study was to investigate whether the effects of 17beta-estradiol tablets that are designed for the treatment of postmenopausal urovaginal atrophy are influenced by the site of placement into the vagina. STUDY DESIGN: In this controlled crossover trial, 10 postmenopausal women received a single 17beta-estradiol tablet in the outer or inner one third of the vagina. Before and 3 hours after treatment, the pulsatility index, resistance index, and blood flow were evaluated in the uterine and periurethral vessels by Doppler examination. Parallel 17beta-estradiol serum evaluations were performed. RESULTS: Comparable and significant increases in 17beta-estradiol were observed. After inner administration, the pulsatility index and resistance index of both uterine arteries decreased; uterine artery blood flow increased significantly (P <.0001) but decreased in periurethral vessels (P <.02). After outer administration, the uterine artery pulsatility index, resistance index, and blood flow did not change, and the periurethral blood flow significantly increased (P <.0001). CONCLUSION: For optimizing the efficacy while minimizing the risk of endometrial hyperplasia, 17beta-estradiol tablets must be placed in the outer one third of the vagina.

Effects of tibolone on plasma levels of nitric oxide in postmenopausal women.

OBJECTIVE: To determine the effects of tibolone on nitric oxide (NO) plasma levels in postmenopausal women. DESIGN: Randomized, double-blind, placebo-controlled, cross-over trial. SETTING: Healthy volunteers in an academic research environment. PATIENT(S): Eighteen healthy women who have been in postmenopause for 1-4 years. INTERVENTION(S): Women received either tibolone 2.5 mg/day (group A) or placebo (group B) for 1 month; then the treatment was inverted for the second month. MAIN OUTCOME MEASURE(S): Plasma concentration of NO stable oxidation products and blood pressure were evaluated at baseline, month 1, and month 2. RESULT(S): Baseline concentration of NO metabolites were similar in both groups. At month 1, mean concentration of NO metabolites increased significantly in group A alone. At the end of month 2, NO metabolite levels in group A returned to baseline, whereas in group B they increased significantly. CONCLUSION(S): Tibolone induced a sustained increase in plasma levels of NO in postmenopausal women, suggesting that tibolone may exert a direct cardiovascular protective effect in postmenopausal women.

Twice-weekly transdermal estradiol and vaginal progesterone as continuous combined hormone replacement therapy in postmenopausal women: a 1-year prospective study.

OBJECTIVE: The purpose of this study was to evaluate the acceptability and endometrial safety of a twice-weekly administration of transdermal estradiol (0.05 mg) systems and vaginal progesterone gel (Crinone [Serono, Rome, Italy] 4%, 45 mg/d) as a continuous combined nonoral hormone replacement therapy regimen. STUDY DESIGN: Thirty-five postmenopausal women took part in this 1-year prospective observational trial. The bleeding pattern, blood pressure, weight, endometrial thickness, and endometrial histologic characteristics of the women were monitored. Mean values were compared before and after treatment by paired Student t tests. RESULTS: Twenty-six (74.3%) women completed the study and were totally amenorrheic. A total of 350 cycles yielded valuable data. Of these, 287 (82%) cycles were amenorrheic. At month 3, blood pressure and weight decreased significantly. At final assessment, endometrial thickness was significantly greater than baseline (4.6 +/- 0.9 vs 3.6 +/- 0.9 mm; P <.0005), and histologic examination revealed endometrial atrophy in 24 (92.3%) cases and signs of decidualization in 2 cases. CONCLUSION: Transdermal estradiol and a twice-weekly administration of the vaginal progesterone gel Crinone constitutes a new, viable hormone replacement therapy regimen. It represents a practical option for a no-bleed treatment, ensuring both high endometrial protection and the inherent safety linked to administrating physiologic hormones nonorally.