Relation of metabolic syndrome with endometrial pathologies in patients with abnormal uterine bleeding.

PURPOSE: We aimed to investigate the association of metabolic syndrome and metabolic risk factors with endometrial hyperplasia and carcinoma among women with abnormal uterine bleeding (AUB). METHODS: This study included 199 patients who had undergone endometrial curettage due to abnormal uterine bleeding. We divided the patients into two groups according to whether they had an abnormal (n = 53) or normal endometrium (n = 146). Waist circumference, blood pressure, fasting glucose and serum lipid levels were measured and statistically analyzed. The women in each group were matched with regard to mean age, gravidity, parity and menopausal status. RESULTS: We found increased prevalence of metabolic syndrome, diabetes, general and abdominal obesity, hypertension, elevated levels of glucose, total cholesterol and LDL-cholesterol and reduced levels of HDL-cholesterol among women with endometrial carcinoma and hyperplasia. These results were detected particularly in postmenopausal (>50 years) women compared to pre-menopausal cases (<50 years). All metabolic parameters were similar between hyperplasia and cancer groups. CONCLUSION: Metabolic syndrome and its components have been shown to have profound impacts on initiation and progession of endometrial pathology, particularly during post-menopausal period.

Evaluation of patients with Behçet's disease by cervical cytology and colposcopic examination.

PURPOSE: We evaluated the genital involvement in women with Behçet's disease (BD) by cervical cytology and colposcopy, and compared these findings with healthy controls. METHODS: A total of 152 women were referred to the Gynecology Clinic of Meram School of Medicine between March 2008 and December 2009. The study group was composed of 78 women with BD, and the control group included 74 healthy women admitted for routine gynecologic examination. These patients were subjected to cervical cytology and colposcopic examination. Cervical biopsy was performed in cases with abnormal cytology. These findings and some gynecologic complaints were compared. RESULTS: The demographic features were similar between each group. Genital involvement (scar + ulcer) was detected in 58 (74.3%) patients. The most common sites of ulcers (55.1%) and scars (7.6%) were the labia majora. Abnormal cytology in study and control groups was detected in nine (11.5%) and three (4%) of the patients, respectively, and a slight statistical significance was obtained (p = 0.048). Acetowhite and iodine-negative epithelium were higher in the study group than in controls (p = 0.015 and p = 0.042). Dyspareunia was higher in BD patients (p = 0.001). CONCLUSION: Patients with BD are more prone to having an abnormal cervical cytology and acetowhite and iodine-negative epithelium on colposcopic examination. However, these findings are mostly benign conditions. The complaint of dyspareunia should be considered during treatment of female patients with BD.

Bilateral adnexal torsion due to postmenopausal hydatidiform mole.

Occurrence of gestational trophoblastic neoplasia (GTN) and adnexal torsion is rare in postmenopause. We report a 58-year-old postmenopausal woman with adnexal torsion caused by hydatidiform mole. The patient was admitted to our clinic complaining of acute abdominal pain, nausea and vomiting lasting one day. Ultrasonography showed an enlarged uterus including hypo/hyperechogenous cystic areas in the endometrial cavity and bilateral adnexal masses. ß-HCG level was investigated and determined as 157.000 IU/l, because of the suspicion of GTN in ultrasonography. Doppler sonography revealed enlarged left adnexa with absence of vascular flow. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. ß-HCG decreased to normal ranges in the fourth postoperative week. The resected uterus contained an endometrial, cystic, grapelike tumor. The ovaries were enlarged bilaterally with necrotic appearance. Histopathology revealed complete hydatidiform mole and theca lutein cysts. To our knowledge, the present case is the first hydatidiform mole associated with bilateral adnexal torsion caused by theca lutein cysts in postmenopausal period.

Assessment of ischemia-modified albumin level in patients with recurrent pregnancy loss during the first trimester.

OBJECTIVE: The finding that ischemia-modified albumin (IMA) is increased in pre-eclamptic pregnancy suggests a role for IMA as a potential biomarker for abnormal placental development related to miscarriage. This study was undertaken to evaluate IMA levels in women with recurrent pregnancy loss (RPL). STUDY DESIGN: This case-control study was performed between March 2008 and September 2009, at the Department of Obstetrics and Gynecology of Meram School of Medicine. Serum IMA and albumin concentrations were assessed in 43 women with a history of two or more unexplained first trimester miscarriages (group 1), and 42 healthy pregnant women (group 2) in the first trimester. IMA, adjusted IMA and albumin concentrations were compared between the groups. Statistical analysis was performed using Student's t-test and Mann-Whitney U test. RESULTS: IMA and adjusted IMA levels were significantly higher in women with RPL (1.11+0.08 and 1.09+0.09, respectively) compared to women in group 2 (0.88+0.10 and 0.88+0.11, respectively). Albumin levels in group 1 were significantly lower compared with group 2. There was a negative correlation between IMAand albumin levels in each group. CONCLUSION: Maternal IMA levels appear to be elevated in women with early RPL. This finding may suggest that an abnormally high hypoxic intrauterine environment may be associated with abnormal placental development that contributes to early miscarriage.

The clinical value of preoperative and intraoperative assessments in the management of endometrial cancer.

OBJECTIVE: In this study, we aimed to investigate the diagnostic accuracy of preoperative assessment and frozen-section analysis (FSA) in endometrial cancer by comparing postoperative histopathology. METHODS: A total of 72 consecutive patients with endometrial cancer were included in this study. Comprehensive surgical staging was performed in all patients. After abdominal hysterectomy, the uterus was investigated for FSA. For preoperative analysis, histological grade and histological subtypes were investigated. In FSA, all the specimens were reviewed for histological subtype, histological grade, depth of myometrial invasion, lymphovascular space invasion (LVI), and cervical involvement. These results were compared with final histopathology. Data were statistically analyzed. RESULTS: The accuracy of preoperative examination was 95.8% (69/72) for histological type and 90% (65/72) for histological grade. In the frozen section, the accuracies of histological grade and subtype were found to be 92% and 98%, respectively. However, histological grade had 43% sensitivity in preoperative and intraoperative assessments. Myometrial invasion and LVI were correctly diagnosed in 93% and 94% of the cases, respectively. The risk assessment was correctly determined in 63 (87%) of 72 patients. Five patients were underclassified, and there was no lymph node invasion in these patients after final histopathology. Lymph node invasion was higher in patients with grade 3 classification, deep myometrial invasion, positive cervical involvement, and LVI. CONCLUSIONS: Frozen-section analysis is a feasible method for the management of the patients with endometrial cancer. However, preoperative and intraoperative assessment of histological grade has lower sensitivity in endometrial cancer.

Induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone.

OBJECTIVE: To compare the effect of an oxytocin infusion alone or preceded by an intravaginal application of misoprostol for labor induction in women with term pregnancies and a low Bishop score. METHODS: This study randomized 100 multiparous women with singleton pregnancies over 38 weeks and a Bishop score less than 6 to receive either a single 50-microg dose of misoprostol intravaginally 3 hours before initiation of the oxytocin infusion or only an oxytocin infusion. The time from induction to delivery, the route of delivery, and maternal and fetal outcomes were analyzed. RESULTS: The mean time from induction to delivery was 9.36+/-1.97 hours in the misoprostol plus oxytocin group and 11.08+/-3.23 in the oxytocin alone group (P=0.002). The rates of vaginal delivery, 1- and 5-minute Agpar scores, placental abruption, and postpartum hemorrhage were similar between the 2 groups, as were the rates of admission to the neonatal intensive care unit. There were no cases of perinatal asphyxia. CONCLUSION: A 50-microg intravaginal application of misoprostol before starting the oxytocin infusion is a more effective method of labor induction than an oxytocin infusion alone for our study population.

The effect of antenatal steroids on fetal lung maturation between the 34th and 36th week of pregnancy.

AIM: To evaluate the effect of antenatal treatment with a single dose of betamethasone between the 34th and the 36th week of pregnancy on the maturation of fetal lung. METHODS: To study 100 pregnant women in their 34th-36th week of pregnancy who were diagnosed as susceptible to have preterm delivery. Fifty patients did not receive betamethasone (group 1). The other 50 patients were administered 12 mg betamethasone in a single dose (group 2). Patients who delivered at least 24 h after the administration of betamethasone were included in this study. After delivery, the Apgar score and the development of respiratory distress syndrome (RDS) in the neonates were compared. RESULTS: Group 2 babies had better Apgar scores when compared to group 1, and the difference was statistically significant. Sixteen (32%) neonates of group 1 and 7 (14%) neonates of group 2 required resuscitation, and the difference was statistically significant (p = 0.032; OR = 0.34, 95% CI 0.12-0.93). RDS was detected in 8 newborns of group 1 and 2 of group 2. The difference was statistically significant (p = 0.046; OR = 0.21, 95% CI 0.04-1.08). CONCLUSION: The administration of a single dose of betamethasone to pregnant women in their 34th-36th week of pregnancy who are likely to have preterm delivery reduces RDS development. There is a need for larger studies to confirm these results.

The efficacy of multiple-dose methotrexate treatment for unruptured tubal ectopic pregnancy and conversion rate to surgery: a study on 294 cases.

In this prospective study 294 patients diagnosed with ectopic pregnancy (EP) were treated with multiple-dose methotrexate (MTX) to determine the conversion rate to surgery. We concluded that multiple-dose MTX treatment had a low success rate, and the success rate was not related to initial b-hCG value; it was more related to the size of gestational mass before treatment.

Evaluation of endometrial thickness with transvaginal ultrasonography and histopathology in premenopausal women with abnormal vaginal bleeding.

OBJECTIVE: This study was undertaken to investigate cut-off value of the endometrial thickness by transvaginal ultrasonography (TvUSG), and to detect the accuracy of preoperative Pipelle biopsy in premenopausal women with abnormal vaginal bleeding. STUDY DESIGN: This study was included 144 premenopausal women with abnormal bleeding. Their endometrial thickness was measured by TvUSG and then Pipelle endometrial biopsy was performed. Preoperative histopathologic findings of 57 women who were operated were compared with final histolopathologic examination. RESULTS: Of the 144 women, 113 (78.4%) had normal and 31 (21.6%) had an abnormal endometrium. The abnormal endometrium was composed of 11.8% hyperplasia (simple + atypical complex), 4.2% endometrial polyp, and 5.5% adenocarcinoma. An optimal sensitivity and specificity (83.6 and 56.4%, respectively) and negative predictive value with 95.6% for detection of abnormal endometrium were obtained with an endometrial thickness of 8 mm. The accuracy rate of preoperative Pipelle biopsy was 94.7% in a total of 57 women. CONCLUSION: An endometrial thickness >8 mm is more likely than that of 8 mm or less to be indicated with endometrial biopsy in premenopausal uterine bleeding. Pipelle endometrial biopsy is an accurate diagnostic procedure for the detection of high-grade endometrial lesions in premenopausal women.

Influence of cumulus cell coculture and cumulusaided embryo transfer on embryonic development and pregnancy rates.

OBJECTIVE: In this study, we aimed to evaluate the influence of autologous cumulus oocyte complex (COC) coculture on embryonic development and quality, and investigate the implantation and pregnancy rates after cumulus-aided embryo transfer in the ICSI-ET cycles. MATERIAL AND METHODS: Ninety five consecutive infertile women undergoing their first cycle of IVF teratment were included in the study. The cases were divided into two groups. Group 1 consisted of 48 women undergoing ICSI, along with autologous cumulus embryo coculture and cumulus-aided emryo transfer. Group 2 comprised 47 consecutive patients who consented to undergo ICSI and in whom autologous cumulus embryo coculture and cumulus-aided embryo transfer were not performed. Implantation and pregnancy rates were compared between the two groups. RESULTS: The demographic data and controlled ovarian hyperstimulation parameters were similar in the two groups. The fertilization and cleavage rates were found to be higher in group 1 when compared with group 2 (p=0.03 and 0.001, respectively). There were no statistical significant differences for the implantation and clinical pregnancy rates between the two groups. CONCLUSION: Usage of autologous COCs as coculture may improve fertilization and cleavage rates. However, cumulus-aided embryo transfer does not produce an increase in implantation and pregnancy rates.

Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism.

OBJECTIVE: To investigate biochemical and metabolic abnormalities in relation with cutaneous features of polycystic ovary syndrome (PCOS). DESIGN: Prospective descriptive analysis. SETTING: University-based tertiary care. SAMPLE: One-hundred and fifteen untreated consecutive women diagnosed as having PCOS. METHODS: Each woman underwent an evaluation of body habitus, acne, hirsutism, seborrhea, androgenic alopecia and acanthosis nigricans. Associations between cutaneous features and hormonal and metabolic parameters were analyzed by means of multivariate logistic regression models. MAIN OUTCOME MEASURES: Prevalence of cutaneous features in PCOS and associations among the features and biochemical and metabolic parameters. RESULTS: The prevalence of acne, hirsutism, seborrhea, androgenetic alopecia and acanthosis nigricans was 53%, 73.9%, 34.8%, 34.8% and 5.2%, respectively. Acne was not associated with the hormonal, metabolic and anthropometric variables. Hirsutism had positive associations with total testosterone, fasting glucose and total cholesterol, and a negative association with age. Seborrhea was found to be related with free testosterone, fasting glucose and insulin. A negative association was determined among androgenic alopecia and free testosterone, low-density lipoprotein and insulin. CONCLUSIONS: Acne and androgenic alopecia are not good markers for the hyperandrogenism in PCOS. Hirsutism appears to be strongly related with hyperandrogenism and metabolic abnormalities in PCOS women.

Assessment of myometrial invasion in endometrial cancer by transvaginal sonography, Doppler ultrasonography, magnetic resonance imaging and frozen section.

OBJECTIVE: We aimed to compare the diagnostic performance of transvaginal sonography (TVS), magnetic resonance imaging (MRI), and intraoperative frozen section in the assessment of myometrial invasion and to evaluate intratumoral blood flow in any myometrial invasion with transvaginal Color Doppler ultrasonography (TV-CDU). METHODS: This prospective study included 64 women consecutively diagnosed with endometrial carcinoma. The subjects were evaluated by TVS, MRI, and TV-CDU by 2 radiologists with a special training in gynecology. Intraoperatively, a frozen section was obtained and processed for interpretation by a blinded pathologist. Sensitivity, specificity, negative, and positive predictive values were calculated for each imaging modality and frozen section with regard to assessment of myometrial invasion. The intratumoral blood flow was evaluated by TV-CDU. RESULTS: Transvaginal sonography, MRI, and frozen section showed no statistical significant differences in overall diagnostic performance for the preoperative and intraoperative assessment of any myometrial invasion, although frozen section seemed to be slightly superior to the imaging techniques. The positive rate of intratumoral blood flow was higher in deep myometrial invasion, but statistical significance was not obtained. The mean value of resistance index was significantly lower in the cases with deep myometrial invasion. CONCLUSIONS: Transvaginal sonography with concomitant TV-UCD is low-cost, easily performed, and repeated technique for particularly deep myometrial invasion. Because of its high costs and time-consuming, MRI may be recommended in the cases with poor quality of TVS. Because depending solely on imaging methods could lead to insufficient treatment schedules, intraoperative frozen section should also be performed for myometrial assessment.

Compared effects of surgical and natural menopause on climacteric symptoms, osteoporosis, and metabolic syndrome.

OBJECTIVE: To compare the effects of surgical (ie, earlier) and natural (ie, later) menopause on climacteric symptoms, osteoporosis, and metabolic syndrome. METHOD: The study was conducted with 94 women who underwent hysterectomy and bilateral oophorectomy and 95 women who were older than 40 years and in natural menopause. None had received hormone therapy or osteoporosis treatment. Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III. RESULTS: The rates of hot flushes (P=0.001), sweating (P=0.001), poor memory (P=0.04), change in sexual desire (P=0.04), and osteoporosis (diagnosed in the hip bone, P=0.005) were significantly higher among the women in surgical menopause, but the rate of metabolic syndrome was similar in the 2 groups (47.8% and 40%; P=0.28). CONCLUSION: Compared with natural menopause, surgical menopause was found to be associated with higher rates of climacteric symptoms and osteoporosis but not of metabolic syndrome.

Long-term effects of valproic acid on reproductive endocrine functions in Turkish women with epilepsy.

The long-term effects of valproic acid (VPA) on reproductive endocrine functions in women with epilepsy (WWE) were studied. Serum reproductive hormone concentrations, clinical findings and ovarian morphology were analyzed in 71 WWE who had been receiving antiepileptic drugs (AED) for a minimum of 2 years. Of the 71 WWE, polycystic ovarian syndrome (PCOS) (p = 0.011) and menstrual irregularities (p = 0.009) were found to be more prevalent in women receiving VPA treatment when compared to women on non-VPA treatment. There was no statistically significant dose or duration-related rise of risk for patients who developed PCOS and menstrual irregularities and those who were not on long-term VPA therapy. The lack of a duration-related reproductive dysfunction in this patient population may support the hypothesis of early occurring VPA-associated metabolic and endocrine changes.

Appendiceal mucocele mimicking a cystic right adnexal mass.

OBJECTIVE: Appendiceal mucocele is formed by cystic dilatation, abnormal mucinous secretion and epithelial proliferation of the appendiceal lumen. Mucocele may be a finding in cases of benign or malignant neoplasms, and can lead to the development of pseudomyxoma peritonei. CASE REPORT: A 71-year-old woman presented with a 3-day history of right lower abdominal pain radiating to her right thigh. A simple 5 x 7 cm cyst with smooth borders and a thick capsule was detected in the right adnexal area by transvaginal ultrasonography. Magnetic resonance imaging identified a 4 x 8 cm cystic lesion in the area of the right ovary. The patient was admitted to our clinic with an initial diagnosis of adnexal cyst, later found to be appendiceal mucocele. CONCLUSION: The signs and symptoms of appendiceal mucocele are not specific. Because of its anatomic position, it should be considered in the differential diagnosis of adnexal masses.

Repeated in vitro fertilization failure and its relation with thrombophilia.

BACKGROUND: The objective of this study was to determine the prevalence of some thrombophilic factors and its relation to in vitro fertilization (IVF)-embryo transfer failure in women who had had three or more previously failed IVF-embryo transfer cycles. METHODS: The study group included 51 consecutive women with three or more previously failed IVF-embryo transfer cycles (group 1). The control group included 50 women who conceived spontaneously with at least one uneventful pregnancy and no previous history of miscarriage. All women were tested for the presence of factor V Leiden, prothrombin (G20210A), and methylenetetrahydrofolate reductase (C677T) mutations. RESULTS: A similar prevalence of factor V Leiden, prothrombin, and methylenetetrahydrofolate reductase mutations was found in both groups. At least one inherited thrombophilic factor was detected in 62.7% of women with repeated IVF failure and in 53.9% of women in group 2. No association between repeated IVF failure and these thrombophilic factors was found statistically. CONCLUSION: These data suggest that factor V Leiden, methylenetetrahydrofolate reductase and prothrombin gene mutation do not have a significant role in IVF-embryo transfer implantation failure.

Treatment of angiokeratoma of Fordyce with long-pulse neodymium-doped yttrium aluminium garnet laser.

BACKGROUND: Angiokeratomas are typically asymptomatic, blue-to-red papules with a scaly surface located on the scrotum, shaft of penis, labia majora, inner thigh, or lower abdomen. The treatment of angiokeratomas may be necessary if they bleed and lead to patient anxiety. OBJECTIVE: To determine the safety and effectiveness of long-pulse 1,064 neodymium-doped yttrium aluminium garnet (Nd:YAG) laser for the treatment of angiokeratomas of Fordyce. MATERIALS AND METHODS: Ten consecutive patients with angiokeratoma of Fordyce were treated with long-pulse Nd:YAG laser in two to six sessions. The three authors independently assessed improvement of the lesion based on digital photographs taken before the treatment and 2 months after the end of the treatment. RESULTS: Significant (>75%, <100%) and moderate (>50%, <75%) improvement was seen in six and two patients, respectively. Complete improvement was achieved in one patient. Transient swelling, purpura, bleeding, and some pain in the treated area were noted in all patients as short-term side effects. There were no permanent side effects. CONCLUSION: The long-pulse Nd:YAG laser is a highly effective and safe treatment for angiokeratoma of Fordyce.

Pyosalpinx caused by the tubal migration of an intrauterine device--a case report.

Migration of an intrauterine device (IUD) is a complication occurring at or following insertion. After having perforated the uterine wall, the IUD usually will settle into the peritoneal cavity. Tubal migration of an IUD is extremely rare and little is known about its mechanism. We describe a case of pyosalpinx caused by the tubal migration of a copper IUD. The tail of the device was embedded in the mesocolon.

Clinical and metabolic effects of medroxyprogesterone acetate and ethinyl estradiol plus drospirenone in women with polycystic ovary syndrome.

OBJECTIVES: To investigate the effects of treatment with medroxyprogesterone acetate (MPA), 10 days per month for 6 months, on lipid and carbohydrate metabolism in women with polycystic ovary syndrome (PCOS). METHODS: Sixty-three women with PCOS were randomized to receive MPA or ethinyl estradiol plus drospirenone. RESULTS: There were no changes in lipid or carbohydrate metabolism in the MPA group, but serum levels of luteinizing hormone (P<0.001) and total testosterone (P<0.003) significantly decreased, as did the free androgen index (P<0.02) and acne (P<0.03) and seborrhea (P<0.04) scores. In the ethinyl estradiol plus drospirenone group lipid and hormone values significantly increased whereas acne, seborrhea, hair loss, and Ferriman-Gallwey scores decreased. There was no statistically significant change in the total cholesterol to high-density cholesterol ratio in either group. CONCLUSION: Treatment of PCOS patients with MPA provided good menstrual cycle control, beneficial changes in hormonal values associated with hyperandrogenism, and no significant changes in lipid or carbohydrate metabolism.

Comparison of multiple dose GnRH antagonist and minidose long agonist protocols in poor responders undergoing in vitro fertilization: a randomized controlled trial.

OBJECTIVE: To investigate the efficacy of gonadotropin releasing hormone antagonist (GnRH) in poor responders undergoing in vitro fertilization. STUDY DESIGN: Ninety-six patients with poor ovarian response in previous treatment cycles were prospectively randomized into two groups. Forty-four patients were stimulated with GnRH antagonist multidose protocol and 45 patients received a standard long agonist protocol. Ovarian response was evaluated by transvaginal ultrasound and hormonal parameters. Cycle characteristics and treatment outcomes were statistically compared between groups. RESULTS: There was significantly reduced duration of stimulation and consumption of gonadotrophins in the antagonist group when compared to the agonist group. The estradiol concentrations on the day of human chorionic gonadotropin (hCG) injection, the number of oocytes retrieved, and the number of embryos transferred were similar for both groups. In the antagonist group, eight (18.1%) ongoing pregnancies were achieved and in the agonist group, ten (22.2%) clinical pregnancies were achieved but the difference was not statistically significant. CONCLUSION: The present study was not powered to detect clinically relevant differences between two protocols in outcomes such as pregnancy rate, with confidence.