RESUMEN

OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 +/- 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 +/- 9.5 and 65.3 +/- 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 +/- 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 +/- 12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.

Asunto(s)

RESUMEN

Angiogenesis plays an important role in neovascularization in tumors. Glycodelin, a hormone-responsive protein, has been detected in tumors of reproductive organs and is found in high levels in the plasma of subjects with gynecological malignancies. Glycodelin is also found in the endothelial cells of the umbilical cord and in the blood vessels of tumors. In this study, we tested whether glycodelin-rich amniotic fluid and a synthetic peptide derived from the sequence of glycodelin peptide (Gp) might promote angiogenic response by examining the migration and tube formation in human umbilical cord vein endothelial cells (HUVECs). Increased migration and tube formation of HUVECs were found in the presence of amniotic fluid and Gp, and this increase was blocked by antibody to Gp and by an anti-vascular endothelial growth factor (VEGF) antibody, suggesting that the angiogenic effects of glycodelin might be mediated by VEGF. The results also showed that Gp significantly increased the release of VEGF protein and mRNA expression in HUVECs, RL-95 (human endometrial carcinoma cells), OVCAR-3 (human ovarian adenocarcinoma cells), EM42 (human endometrial epithelial cells), THP-1 (human monocyte), and MCF-7 and MDA-MB-231 (human breast adenocarcinoma cells) cell lines. VEGF receptor Fit-1 mRNA expression in HUVECs was also increased in the presence of Gp. These findings, together with the suggestion from the literature that glycodelin may have immunosuppressive properties, suggest that glycodelin might play an important role in neovascularization during embryogenesis and tumor development.

Asunto(s)

RESUMEN

More than 90% of gynecologic surgery is performed for nonmalignant conditions, with a major objective of improving the patient's health-related quality of life (QOL). Clinical studies and patient surveys demonstrate that fatigue, diminished energy levels, increased need for rest, delayed time to return to work, difficulty performing daily routines, and difficulty caring for family and home persist for weeks to months or more following surgery. The social and economic implications of these outcomes provide a rationale for improving the QOL of gynecologic patients in the early weeks of recovery from surgery. Persistent and debilitating fatigue, which can lead to diminished QOL, is even more common than pain following hysterectomy. Global and specific subjective self-assessment instruments have been developed to measure fatigue as well as QOL parameters in postoperative gynecologic surgery patients. In addition, a QOL instrument combining both subjective self-assessment scales and objective measures of hemoglobin, hematocrit and muscle strength has been validated in postoperative orthopedic patients and may also have application in gynecologic surgery patients. Collectively, these various instruments may be useful in the assessment of recuperative power and vitality during early postoperative recovery in patients undergoing gynecologic surgery.

Asunto(s)

RESUMEN

OBJECTIVES: To document long-term medical, surgical and psychosexual outcome of individuals with congenital micropenis (13 males, 5 females). METHODS: Physical measurements from childhood were collected retrospectively from medical records and at adulthood by physical examination. An adult psychosexual assessment was conducted with a written questionnaire and oral discussion. RESULTS: Adult penile length was below the normal mean in all men. Three women had vaginoplasty resulting in normal length. All men reported good or fair erections but 50% were dissatisfied with their genitalia. Dissatisfaction with body image resulted from having a small penis (66%), inadequate body hair (50%), gynecomastia (33%) and youthful appearance (33%). Ten men were heterosexual, 1 homosexual and 2 bisexual. Among women, 4 (80%) were dissatisfied with their genitalia. Three women reported average libido with orgasm and were also heterosexual. Two women had no sexual interest or experience. Finally, males were masculine and females feminine in their gender-role identity, and both groups were satisfied with their sex of rearing. CONCLUSIONS: Regarding choice of gender, male sex of rearing can result in satisfactory genito-sexual function. Female gender can also result in success, however it requires extensive feminizing surgery.

Asunto(s)

RESUMEN

OBJECTIVE: To determine whether retinoic acid (RA) can regulate the expression of interleukin (IL)-6 in human endometrial cells in a manner that might be beneficial to women with endometriosis. DESIGN: In vitro study. SETTING: Academic medical center. PATIENT(S): Patients with endometriosis and controls. INTERVENTION(S): Endometrial cell cultures were treated with RA. MAIN OUTCOME MEASURE(S): Interleukin-6 protein secretion, messenger RNA expression, and IL-6-promoter activity. RESULT(S): Using a human endometrial cell line (EM42), as well as primary stromal and epithelial endometrial cells, we demonstrated that RA suppresses IL-6 protein and messenger RNA expression in a time- and dose-dependent fashion, showing maximal effects at pharmacologically achievable blood serum concentrations (micromoles per liter). Retinoic acid specifically inhibited the activity of IL-6-promoter reporter constructs that were transiently transfected into EM42 cells. Mutational analysis of reporter constructs indicated that RA suppression of IL-6 expression was mediated, at least in part, through the nuclear factor IL-6 binding site located in the IL-6 promoter. CONCLUSION: Retinoids may play a fundamental role in altering the pathophysiology of endometriosis related to aberrant production of IL-6.

Asunto(s)

RESUMEN

OBJECTIVE: We recently reported the presence of glycodelin in the endothelial cells of human umbilical cord. The objective of the current study is to determine whether human umbilical cord endothelial cells synthesize glycodelin. DESIGN: Controlled clinical study. SETTING: Healthy women undergoing normal delivery at Grady Memorial Hospital, Atlanta, Georgia. PATIENT(S): Healthy women undergoing normal delivery. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Human umbilical cord was collected after full-term delivery and total RNA from endothelial cells was isolated. Reverse-transcription polymerase chain reaction (RT-PCR) was performed by using primers from glycodelin sequence. Human umbilical cord endothelial cells at passage 3 were incubated with glycodelin-derived peptide or glycodelin-rich amniotic fluid. Immunocytochemical analysis was performed by using purified chicken anti-glycodelin peptide antibody to detect the accumulation of glycodelin in cells. RESULT(S): Little or no glycodelin message was detectable in the endothelial cells from human umbilical cord vein by RT-PCR and Southern blot analysis. However, these cells readily took up glycodelin protein and glycodelin-derived synthetic peptide from the medium. CONCLUSION(S): The presence and accumulation of glycodelin in the umbilical cord might indicate their potential role in the survival of fetal tissue in the maternal environment.

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVE: To assess the safety and efficacy of hysteroscopic resection of the uterine septum in patients with a Class Va septate uterus. DESIGN: Retrospective clinical study. SETTING: University outpatient surgical center. PATIENT(S): Twenty-one patients with Class Va uterus treated between 1985-1998 in the senior author's academic practice. INTERVENTION(S): Hysteroscopic metroplasty with preservation of cervical septum. MAIN OUTCOME MEASURE(S): Intraoperative and postoperative complications; postoperative cumulative pregnancy and delivery rates. RESULT(S): No long-term complications were encountered. Fourteen of 15 women who attempted pregnancy postoperatively delivered viable neonates; the 15th is in an ongoing pregnancy. CONCLUSION(S): Surgical correction of the complete uterine septum with preservation of the cervical septum is associated with low morbidity and satisfactory postoperative obstetric outcome.

Asunto(s)

RESUMEN

OBJECTIVE: To determine the duration of time to the recurrence of pain attributable to endometriosis after the discontinuation of treatment with danazol or a GnRH agonist (GnRH-a) in patients who have had a satisfactory response to the treatment. DESIGN: Retrospective study. SETTING: Nine academic medical centers in three countries. PATIENT(S): Three hundred twenty-seven women with diagnosed and staged endometriosis who were treated with at least 6 months of danazol or a GnRH-a and who experienced significant pain relief with therapy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Duration of pain relief after completion of treatment as determined by a patient-initiated report of pain recurrence or increase in pain severity requiring intervention. RESULT(S): The median time to the recurrence of pain was 6.1 months for patients treated with danazol and 5.2 months for patients treated with a GnRH-a. CONCLUSION(S): Although there was a lack of uniformity in treatment effects across sites, the analyses have taken into account major covariant effects. The time to the recurrence of endometriosis-associated pain after danazol treatment was slightly longer than that after GnRH-a treatment.

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVE: To determine whether the immediate initiation of estrogen replacement therapy (ERT) in the postoperative period increases the incidence of symptom recurrence following total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) for the treatment of endometriosis. METHODS: In a retrospective cohort study, 95 women who underwent TAH with BSO for endometriosis at the Johns Hopkins Hospital during 1979-1991 and who subsequently received ERT were identified by computer search. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. Pain recurrence in patients who started ERT within 6 weeks after surgery and in those who delayed ERT for more than 6 weeks was compared and adjusted for length of patient follow-up and other covariates. RESULTS: Sixty women began ERT within the immediate postoperative period, and four (7%) of them had recurrent pain; 35 women began ERT more than 6 weeks after surgery, and seven (20%) of them had recurrent pain. The mean length of follow-up was 57 months. The difference in the crude rate of symptom recurrence following early and delayed initiation of ERT after TAH with BSO was not statistically significant (P = .09). Controlling for length of patient follow-up, no significant differences were observed between the two groups. Adjusting for covariates of stage, age, and postoperative adjunct medroxyprogesterone therapy, those who started ERT more than 6 weeks after surgery had a relative risk of 5.7 (95% confidence interval 1.3, 25.2) for pain recurrence. CONCLUSION: Although the number of patients in the study was too small to reach statistical significance in all analyses, these findings suggest that patients who begin ERT immediately after TAH with BSO are at no greater risk of recurrent pain than those who delay ERT for more than 6 weeks.

Asunto(s)

RESUMEN

OBJECTIVE: To develop and characterize an antiglycodelin antibody using a 15-amino acid synthetic peptide as antigen, derived from the sequence of human glycodelin. DESIGN: We have developed a chicken antiglycodelin-derived peptide antibody and have characterized the antibody with the use of endometrial and ovarian cell lines. The antibody was also tested for its ability to detect glycodelin by ELISA assay, immunocytochemistry, and by Western blot. SETTING: Various cell lines, cell culture medium, and amniotic fluid were used in the experiments. PATIENT(S): Amniotic fluid was collected from pregnant patients in their first trimester of pregnancy. INTERVENTION(S): No intervention. MAIN OUTCOME MEASURE(S): Detection of glycodelin. RESULT(S): The cell lines RL95-2 (human endometrial carcinoma cells), OVCAR-3 (human ovarian adenocarcinoma cells), HeLa (human cervical epitheloid carcinoma cells), and EM42-D (human endometrial epithelial cells) reacted with the antibody, indicating the presence of glycodelin. A specific 45-kd protein representing glycodelin was detected by Western blot in the amniotic fluid. CONCLUSION(S): Antipeptide antibodies can be successfully used to detect and quantify the presence of glycodelin in cells and fluids.

Asunto(s)

RESUMEN

Classification systems for endometriosis continue to evolve. Past systems have been modeled primarily after those in use for grading malignant disease. Unfortunately, classification methods that attempted to quantitate the severity of disease have suffered from only modest predictability in determining outcome. The 1985 revised American Fertility Society classification system is limited by scoring arbitrariness, potential for observational error, limited reproductivity, failure to consider lesion morphologic type and a particularly poor correlation with pelvic pain. These shortcomings are being presently addressed.

Asunto(s)

RESUMEN

OBJECTIVE: To describe a technique for surgical management of complete obliteration of the endometrial cavity. DESIGN: A report of a series of three patients. SETTING: A university-based hospital. PATIENT(S): Three patients with complete obliteration of the endometrial cavity. INTERVENTION(S): Transfundal scar removal using stents in the fallopian tubes to serve as landmarks. MAIN OUTCOME MEASURE(S): Regular withdrawal bleeding. RESULT(S): Regular menses in all three patients. CONCLUSION(S): The technique described here show promise for establishing uterine cavity integrity in cases of complete endometrial obliteration where there are no landmarks in the uterine cavity.

Asunto(s)

RESUMEN

OBJECTIVE: To determine whether anionic ligands for the macrophage scavenger receptor inhibit the fertilization of mouse oocytes by mouse spermatozoa. DESIGN: In vitro study of sperm binding and two-cell embryo formation in the presence of scavenger receptor ligands. Sperm-oocyte interaction may be mediated by sulfated sugars. In this study, we tested other nonsulfated anionic ligands for the scavenger receptor for their ability to affect fertilization. The only common feature of these ligands is their anionic nature. SETTING: Oocytes and sperm from mice were used. MAIN OUTCOME MEASURE(S): Binding of sperm to oocytes and subsequent formation of two-cell embryos were determined. RESULT(S): Fucoidin, polyinosinic acid, oxidized low-density lipoprotein, acetyl low-density lipoprotein, and malondialdehyde-modified LDL inhibited the binding and fertilization of mouse sperm to mouse oocytes. Addition of fresh sperm to oocytes previously treated with sperm in the presence of these agents restored the binding and fertilization. CONCLUSION(S): These results show that charge-based interactions analogous to the interactions of the scavenger receptor with its ligands may play an important role in mammalian fertilization.

Asunto(s)

RESUMEN

OBJECTIVE: The objective of the study was to determine whether Interceed oxidized regenerated cellulose (Johnson & Johnson Medical, Arlington, Tex.), because of its polyanionic nature, may compete for the macrophage scavenger receptor. STUDY DESIGN: RAW macrophages were incubated with Interceed oxidized regenerated cellulose and known scavenger receptor ligands. The production of interleukin-1beta by mouse peritoneal macrophages was measured in the presence of Interceed cellulose. RESULTS: When macrophages were incubated with Interceed cellulose, increasing concentrations inhibited the uptake of fluorescent acetyl low-density lipoprotein. In the presence of Interceed cellulose there was a decrease in the production of interleukin-1beta by mouse macrophages. CONCLUSION: These results suggest that the interaction of Interceed oxidized regenerated cellulose with macrophages with scavenger receptors may result in a decreased secretion of matrix components, inflammatory mediators, and cellular growth factors. Thus Interceed cellulose may function as a biologic barrier in preventing adhesions.

Asunto(s)

RESUMEN

OBJECTIVE: To determine the incidence, clinical stage, and lesion type of endometriosis in adolescent girls. DESIGN: Retrospective review of patient records of adolescent girls (11-19) admitted to Emory University Affiliated Hospitals. SETTING: Patients from a private practice institutional setting. PATIENTS: 67 adolescent girls who had not responded to analgesia or oral contraceptives for pelvic pain. INFORMATION: Laparoscopy or exploratory laparotomy to determine the etiology of pelvic pain. MAIN OUTCOME MEASURE: Stage of endometriosis by the American Fertility Society classification system and description of lesion type. RESULTS: Endometriosis was diagnosed in 49 (73%) patients. The majority of patients had stage I disease. Superficial red lesions were most commonly observed. CONCLUSIONS: Adolescent girls with pelvic pain have a high incidence of endometriosis. Minimal disease is most often encountered. Meticulous inspection of the pelvic peritoneal surfaces will often reveal superficial or atypical lesions.

Asunto(s)

RESUMEN

OBJECTIVES: To elucidate further the antioxidant properties of RU486. We determined whether it can protect biologic molecules such as proteins (albumin, low-density lipoprotein [LDL] and oxidized LDL) from damage by pre-existing lipid peroxides. DESIGN: In vitro study. INTERVENTIONS: We tested the effects of RU486 on the formation of fluorescent oxidatively modified proteins by pre-existing lipid peroxides. We used two model systems, the incubation of oxidized linoleic acid with serum albumin and the incubation of human LDL with copper. MAIN OUTCOME MEASURES: The formation of modified protein was established by determining fluorescence at excitation wavelength of 330 nm and emission wavelength between 390 and 500 nm. Modified protein has a characteristic emission between 425 and 430 nm. RESULTS: The addition of increasing amounts of RU486 inhibited the formation of fluorescent oxidatively modified protein products in both model systems. CONCLUSION: These results provide evidence that RU486 not only can prevent the formation of lipid peroxide, but also can block the formation of fluorescent protein adducts in the presence of pre-existing lipid peroxides.

Asunto(s)

RESUMEN

OBJECTIVES: To determine the relative risk of symptom recurrence and/or reoperation after hysterectomy with ovarian preservation for the treatment of endometriosis. DESIGN: Historical prospective study of patients with endometriosis who underwent hysterectomy with or without ovarian preservation. PATIENTS: One hundred thirty-eight women who underwent hysterectomy with the diagnosis of endometriosis. METHODS: A computer search identified 138 women who underwent hysterectomy with the diagnosis of endometriosis at Johns Hopkins Hospital from 1979 to 1991. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. RESULTS: Twenty-nine women had hysterectomy with some ovarian tissue preserved; 109 had all ovarian tissue removed. Of those with ovarian preservation, 18 of 29 (62%) had recurrent pain and 9 of 29 (31%) required reoperation. Of those who had no ovarian preservation, 11 of 109 (10%) had recurrent symptoms and 4 of 109 (3.7%) required reoperation. Ovarian conservation was associated with a relative risk for pain recurrence of 6.1 (95% confidence interval [CI] 2.5 to 14.6) compared with patients with oophorectomy in a Cox proportional hazards model. The relative risk for reoperation in patients with ovarian conservation was 8.1 (95% CI 2.1 to 31.3). CONCLUSION: Compared with women who had oophorectomy for endometriosis, patients who underwent hysterectomy with ovarian conservation had 6.1 times greater risk of developing recurrent pain and 8.1 times greater risk of reoperation.

Asunto(s)

RESUMEN

Studies reveal endometriosis to be present in 38-51% of women undergoing laparoscopy for chronic pelvic pain. Symptoms attributable to endometriosis include dysmenorrhea, dyspareunia, generalized pelvic pain, dyschezia, and radiation of pain to the back or leg. Psychological factors may also contribute to a more intense pain experience. Medical therapy provides symptom relief in 72-93% of patients, although recurrence is common following treatment discontinuation. Surgical therapy has had varying results for long-term pain relief; adequacy of the initial surgical treatment appears to be a critical factor. Important adjunctive measures include presacral neurectomy and excisional techniques to remove deep, fibrotic, retroperitoneal lesions. The quality of life of women with endometriosis will improve with greater focus on achieving the long-term relief of pelvic pain. Limitation of pain recurrence would benefit the patient greatly, by providing symptom relief and preventing the cycle of its probably adverse effects on physical activity, work productivity, sexual fulfilment, and mood.

Asunto(s)