History Of Abnormal Uterine Bleeding Research Articles

Correlation Of Structural Uterine Abnormalities With Abnormal Uterine Bleeding Among Premenopausal Women With Infertility

Objective: To document the various structural uterine abnormalities detected on transabdominal ultrasonography (TAUS) and hysterosalpingography (HSG) of premenopausal women with infertility and abnormal uterine bleeding (AUB) and determine whether the structural abnormalities correlate well with the clinical forms of AUB among the patients. Methodology: This is a prospective and analytical study of 98 infertile women with history of AUB, referred for HSG. Clinical history including the forms of AUB were obtained from the subjects. Subjects were evaluated with TAUS and HSG after obtaining both ethical clearance and informed consent. Statistical analysis was with the Statistical Package for Social Sciences (SPSS) version 21. Simple frequency, measures of central tendency and dispersion, crosstabulation as well as Pearson’s correlation tests were carried out. For correlation, p ≤ 0.05 was considered significant. Result: Fibroids, followed by intrauterine adhesions (IUA) were the commonest structural uterine abnormalities. Fibroids were detected with both TAUS and HSG, while IUA were detected with HSG only. Shortened menstrual flow was the commonest form of AUB and occurred in 52 (53.1%) of the subjects, followed by light menstrual flow 41(41.8%). The menses were irregular in 33(33.7%), light and shortened in 32(32.7%), heavy in 21(21.4%), prolonged in 16(16.3%), and, heavy and prolonged in 9(9.2%). Fibroids occurred most frequently among those with heavy and prolonged menstrual bleeding while IUA occurred most frequently among those with scanty and reduced menstrual bleeding. On TAUS, HSG, or combined TAUS and HSG, there were significant correlations between fibroids and prolonged heavy menses, fibroids and heavy menses, and, fibroid and prolonged menses. On HSG, significant correlation existed between IUA and scanty short menses. Conclusion: Uterine fibroids and intrauterine adhesions were the commonest structural uterine abnormalities detected. There was significant correlation between fibroids and history of heavy menstrual flow as well as between fibroids and prolonged menses, and IUA and scanty short menses.

Uterine MEIS1::NCOA2 Fusion Sarcoma With Lung Metastasis: A Case Report and Review of the Literature.

MEIS1::NCOA1/2 fusion sarcomas are a recently described novel entity arising in a variety of locations with a predilection for the genitourinary tract and gynecologic organs. Despite multiple locoregional recurrences, these tumors are thought to behave in a low-grade malignant manner. Here we report a uterine MEIS1::NCOA2 fusion sarcoma with lung metastasis. The patient was a 47-yr-old woman with a history of abnormal uterine bleeding who was found to have a myometrial mass confirmed by pathology to be uterine sarcoma. The tumor was predominantly composed of monotonous spindle cells with scant cytoplasm, crowded nuclei, and brisk mitotic activity, growing in a fascicular and streaming pattern. The morphologic and immunophenotypic features were nonspecific and a diagnosis of high-grade uterine sarcoma with a differential of leiomyosarcoma versus high-grade endometrial stromal sarcoma was rendered. At the 27-mo follow-up, the patient was found to have a lung metastasis consisting of a monotonous round cell sarcoma. A retrospective RNA-based and DNA-based next-generation sequencing of the primary uterine sarcoma revealed a MEIS1::NCOA2 gene fusion, a c.94G>C/p.D32H mutation in exon 3 of CTNNB1 gene, HMGA2, and CDK4 gene amplification, and an intermediate/marginal level of MDM2 gene amplification. Polymerase chain reaction-based molecular analysis further demonstrated that the MEIS1::NCOA2 gene fusion and CTNNB1 somatic mutation were also present in the lung metastasis. This case represents the first case of such gynecologic sarcoma with distant (lung) metastasis, and the second metastatic case among all reported MEIS1::NCOA1/2 fusion sarcomas, highlighting the malignant metastatic potential of this emerging entity. Our case also indicates that HMGA2/CDK4/MDM2 region amplification and CTNNB1 somatic mutation might be recurrent genetic events in this rare sarcoma subtype.

Prognostic Role of Human Epididymis Protein4 (HE4) in Endometrial Lesions: Study in a Tertiary Care Centre.

Endometrial cancer accounts for 20% of malignant tumours in the female reproductive system. A novel biological marker human epididymis protein4 (HE4) represents an important alternative indicator which may benefit patient mortality. To correlate the immunohistochemical expression of HE4 in different non-neoplastic and neoplastic endometrial lesions and with the WHO grade of the tumours. Our study was a cross-sectional, observational study done in a tertiary care hospital from December 2019 to June 2021 on the hysterectomy sample of 50 patients with a clinical history of abnormal uterine bleeding and pelvic pain. The study showed strong positivity of HE4 in cases of endometrial carcinoma, weak positivity in cases of atypical endometrial hyperplasia, and negativity in cases of endometrial hyperplasia without atypia group. WHO grade 3(50%) and grade 2 (29%) endometrioid adenocarcinoma NOS in our study showed strong positivity for HE4 which was statistically significant (P value = 0.001). In recent studies using overexpression of HE4-related genes, the malignant biological behaviour such as cell adhesion, invasion, and proliferation was enhanced. It was seen in our study that strong positivity of HE4 was seen in all endometrial carcinoma groups and with higher WHO grade. So, HE4 may become a potential therapeutic target for advanced-stage endometrial carcinoma which requires further research. Thus, human epididymis-specific protein 4 (HE4) has been shown to be a promising marker for the detection of endometrial carcinoma patients who could be benefitted from targeted therapy.

Making Use of the Tools in the Toolkit: Combined Transcervical Radiofrequency Ablation and Hysteroscopic Myomectomy

<h3>Study Objective</h3> To highlight and describe the combined use of radiofrequency ablation and hysteroscopic myomectomy to address symptomatic uterine fibroids. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is a 41-year-old patient G2P1011 patient with a history of abnormal uterine bleeding and uterine fibroids. Her past surgical history was significant for an exploratory laparotomy for an ectopic pregnancy, a robotic-assisted laparoscopic myomectomy, as well as a 2-staged hysteroscopic myomectomy. <h3>Interventions</h3> Preoperative pelvic ultrasound showed an enlarged uterus with a 4.1 × 3.7 × 5.2 cm FIGO type 1 fibroid extending from the left uterine fundus into the endometrial cavity. The patient opted for a combined procedure of transcervical radiofrequency ablation and hysteroscopic myomectomy to maximize her chances of success; given her prior failed treatments. <h3>Measurements and Main Results</h3> The radiofrequency ablation portion of the case was completed first; with three overlapping zones of ablation completed on the fibroids. The submucosal component of the fibroid was then resected using the resectoscope. The patient tolerated the procedures very well, no complications were encountered. She was discharged on the same day of her procedure with non-opioid analgesics. <h3>Conclusion</h3> Uterine preserving, concomitant use of multi-modality surgery can be considered for patients presenting with symptomatic uterine, including those with significant intramural and submucosal components. Combining minimally invasive tools such as radiofrequency ablation and hysteroscopic myomectomy can offer patients safe and effective alternatives in management of recurrent and recalcitrant leiomyomas.

Levonorgestrel Intrauterine System (MIRENA): Initial Experience in the Management of Abnormal Uterine Bleeding

Introduction: The Levonorgestrel intrauterine system (MIRENA) is a long acting contraceptive device act by releasing progesterone into the uterus It is also efficient in medical management of abnormal uterine bleeding. Levonorgestrel intrauterine system is best option for those ladies who want to avoid surgery in cases of abnormal uterine bleeding.&#x0D; Aims: To assess the effectiveness of MIRENA in abnormal uterine bleeding.&#x0D; Methods: This is a hospital based cross sectional study done at the department of obstetrics and gynecology in ladies with history of abnormal uterine bleeding. The study was done from January 2020 to January 2022 for a period of two years. Data were collected, recorded in standard Proforma and analyzed by using EESPPS version 17.&#x0D; Results: Majority of patients were multipara of age group 35-40 yrs. Mirena caused decrease in heavy menstrual blood loss by 2.4% in 4month of use and 47.6% by one year. After one year of use 83.3% patient had better compliance, 9.5% had expulsion, and only 7.1% had to undergo hysterectomy.&#x0D; Conclusion: Mirena is the best alternative in the medical management of abnormal uterine bleeding with good patient compliance reducing the rate of hysterectomy.

Embryonal Rhabdomyosarcoma in the Pelvis of a 22-Year-Old Female: A Case Report

Embryonal rhabdomyosarcoma is a rare soft-tissue sarcoma that is responsible for less than 1% of malignancies in the adult population. We present a case of a 22-year-old female with a six-month history of abnormal uterine bleeding that was found to have an exophytic mass within the cervix. Magnetic resonance imaging was performed and revealed a large pelvic mass. Further workup included biopsies and surgical removal of the tumor, leading to the diagnosis of embryonal rhabdomyosarcoma. PET scan showed no FDG-avid malignancy, aiding in the decision-making process for adjuvant treatment to include vincristine, actinomycin D, cyclophosphamide, and mesna. This case is important to document due to the rarity of this disease and to serve as a reminder to gynecologists to consider the addition of rhabdomyosarcoma in the differential diagnosis when evaluating young adult females presenting with abnormal uterine bleeding and a cervical mass lesion.

Anaesthetic management of a case of large ASD with severe pulmonary hypertension\u2014case presentation

BackgroundAtrial septal defect is the most common acyanotic congenital cardiac anomaly in the adults after bicuspid aortic valve with high prevalence in females. Major challenges in the management of large ASD with severe pulmonary hypertension includes hypoxemia, hypercarbia, hypothermia leading to reversal of shunt (Eisenmenger syndrome), fatal arrhythmias and congestive heart failure.Case presentationWe report the successful management of the case of 44-year-old female patient with large ASD and severe pulmonary arterial hypertension posted for total abdominal hysterectomy with salpingectomy. She had history of palpitations with exertional dyspnoea and history of abnormal uterine bleeding with failed medical treatment. Echocardiography showed large OS-ASD (24 mm) with left to right shunt, moderate TR, severe PAH with estimated RVSP 60 mmHg, LVEF 50% and grossly dilated RA/RV. She underwent total abdominal hysterectomy with salpingectomy under regional anaesthesia with prophylactic use of adrenaline infusion.ConclusionsCardiac patients for non-cardiac surgery can be managed under regional anaesthesia.

Clarification of Ki67 Expression in Association with the Histological Picture of Endometrium in Cases with Abnormal Uterine Bleeding in Nineveh Province

Background: Among the frequent daily challenges in the practice of gynecology are abnormal uterine bleeding (AUB) beside the distinction of fundamental endometrial lesions that stand behind it .Ki67 is among the excellent markers as the higher proliferation rate is one of the features of cancer cells. Aim: This study aims to clarify the expression of Ki67 in the endometrium of women suffering from abnormal uterine bleeding in Nineveh Province and to correlate its expression with the histological picture. Subjects, Materials, and Methods: This is a case series study that was enrolled analysis of data (retrospectively and prospectively) of 51 females who were presented with history of abnormal uterine bleeding and they were underwent an elective D&C and or hysterectomy after admission in several Hospitals, in Nineveh Province, Northern Iraq from 1st January, 2020 to 30th December, 2020. The selected paraffin blocks (n-=51) were cut into 3-4 micrometers thick sections and mounted on poly-L-lysine glass slides for immunohistochemical staining with using of positive and negative control sections at Unit of Immunohistochemistry in Vin Hospital -Duhok-North of Iraq. Staining was performe using the optimized protocol recommended by the International Ki67 in Breast Cancer Working Group together with Dako Autostainer according to manufacturer instructions. Results: This work revealed that 23(45%)out of 51 cases were aged >50 years.The highest mean of percentage of Ki67expression was in sections of proliferative endometrium.In fact, sections of 3/7 of cases which were exhibited a percentage of Ki67 expression from 76% to 100% aged >50 years, while sections of 3/7 of cases of menopause women showed percentage of Ki67 expression from 26% to 75 %. Further, 12 cases out of 17 showed an intensity of staining score of 2 were aged ˂50 years, while 3 out of 5 cases (which revealed an intensity of 3 ) were aged < 50 years. Five cases out of 17 which showed an intensity of staining score of 2 were aged >50 years, while 2 out of 5 cases which exhibited an intensity score of 3 were aged > 50 years. The current study showed that 11/16 cases of benign conditions presented with percentage of Ki67 expression of less than 25%,while 14/15 cases of endometrial hyperplasia presented with Ki67 expression of <25%.In contrary, 8 cases out of 20 ofcases of endometrial adenocarcinomashowedKi67 expression of >25%. Further,the intensity ofKi67 immunostaining of more than 2 was shown in 4 cases of endometrial adenocarcinoma. Regarding cases of endometrial hyperplasia, the current work revealed that 7 cases (46%) out of 15 cases were aged more than 50 years. About 4 cases (26%) of them are of atypical type withno significant differences between the percentage and intensity of Ki67 expression in cases of endometrial hyperplasia. In fact, 15 cases (75%) of endometrial adenocarcinoma were aged more than 50 years. Four (20%) of them were of grade 3, while six cases (30%) of them were of grade 2.According to the grade of endometrial adenocarcinoma, sections of 2 out of 5 cases of grade one (well differentiation) endometrial adenocarcinoma showed the percentage of Ki67 expression of more than 15%, while 5 out of 10 cases of grade 2 (Moderately differentiation) endometrial adenocarcinoma showed the percentage of Ki67 expression of more than 15%. Finally, 3 out of 5 cases of grade 3 (poorly differentiation) endometrial adenocarcinoma showed the percentage of Ki67 expression of more than 15%. About 5 cases out of 16 with Ki67 expression of more than 25%.Finally, 8 cases out of 20 cases of endometrial adenocarcinoma showed the Ki67 expression of more than 25%. Conclusion: Analysis of immunohistochemical expression of Ki67 in sections of women presented with AUB revealed that there is a relation with the age of patients. A significant association between expression of the Ki67 and poor tumor characteristics was conclude. Significant differences was shown between the expression of the Ki67 in sections of proliferative phase and those of endometrial hyperplasia ,while significant differences was found between the expression of the Ki67 in sections of endometrial hyperplasia and those of endometrial carcinoma. Using of Ki67 as diagnostic and prognostic tool in endometrial carcinoma may be conclude.

A Rare Case of Cavernous Angiomatosis of the Uterus

Abstract Introduction/Objective Angiomatosis is a rare, non-neoplastic vascular malformation characterized by the proliferation of blood vessels which involve skin, soft tissue, and bone. Angiomatosis of the female genital tract is extremely rare with very few cases described in the English literature. Methods/Case Report We present a case of an unexpected finding of angiomatosis of the uterus and cervix in a 34- year-old nulliparous female with a history of abnormal uterine bleeding and dysmenorrhea of one year duration. Imaging studies showed an anteverted uterus measuring 9 cm × 6 cm × 5 cm with thickened irregular endometrium, blood clots within the endometrial cavity, and subserosal uterine fibroids. A subsequent endometrial curettage showed benign superficial endometrium. Hysterectomy was performed and histopathological examination revealed diffuse haphazardly arranged large vascular channels within the uterine wall and cervical stroma. A diagnosis of cavernous angiomatosis of the uterus and cervix was made. Results (if a Case Study enter NA) NA Conclusion Angiomatosis of the female genital tract is a rare vascular proliferation that tends to grow at a slow rate and cause heavy menstrual bleeding in otherwise healthy patients. Differential diagnoses of angiomatosis include other vascular tumors such as hemangiomas, lymphangioma, arteriovenous malformation and papillary endothelial hyperplasia. Clinical examination and investigations like hysteroscopy, endometrial curettage and ultrasonography may not help in accurate diagnosis. Definitive diagnosis relies heavily on histopathological examination. Treatment of symptomatic angiomatosis is purely surgical and in our case, was curative. Following treatment, recurrences can occur and appropriate surveillance is recommended. Malignant transformation have not been reported. It is important to be aware of this rare entity to make an accurate diagnosis.

Mesonephric Adenocarcinoma of Uterine Cervix; A Case Report and Review of the Literature

Mesonephric adenocarcinoma of the uterine cervix is an extremely rare tumor of the female genital tract which derives from the remnants of embryonic mesonephric ducts and its prognosis, diagnosis and treatment is rather challenging. We report a case of a 46-year-old woman with history of abnormal uterine bleeding and an enlarged uterine cervix on physical examination without obvious mass lesion. She was clinically underdiagnosed with cervical myoma and mesonephric hyperplasia. After simple hysterectomy, stage IB2 mesonephric adenocarcinoma was diagnosed. Despite adjuvant chemoradiation, she presented with peritoneal and locoregional recurrence in less than a year. So, in the presence of abnormal bleeding and cervical mass, mesonephric hyperplasia in cervical biopsy specimen should be suspected for adenocarcinoma. Radical hysterectomy and complete staging with or without salpingo-oophorectomy is the mainstay of treatment. Despite all ambiguities, due to the small number of reported cases, the overall prognosis seems to be less favorable than conventional cervical adenocarcinoma.

Uterine Arteriovenous Malformation Acquired after Cesarean Section: A Case Report

Background: Uterine arteriovenous malformation (AVM) is a rare, potentially life-threatening cause of abnormal uterine bleeding that can be acquired following a cesarean section. The diagnosis is difficult, often misdiagnosed with retained products of conception and placenta accreta. Transarterial embolization (TAE) is an efficacious and effective method of treating AVM, particularly in patients of reproductive age. Case Report: A 41-year-old, nulliparous woman, started with a history of abnormal uterine bleeding 30 days after a cesarean section. She didn’t have anaemia and beta-human chorionic gonadotropin (beta-hCG) was negative. The transvaginal color Doppler ultrasound showed multiple vascular channels within myometrium showing colored mosaic patterns suggesting AVM, confirmed by Magnetic Resonance Imaging. The patient was referred to perform a Computed Tomography Angiography and right uterine artery embolization without any vascular complications. Conclusion: AVM is a rare consequence of cesarean section but has to be considered in cases of persistent uterine bleeding in the puerperium. Embolization is a safe and effective choice treatment of AVM and an alternative and less invasive option for patients wishing to preserve fertility.

Rates of Intrauterine Device Expulsion Among Adolescents and Young Women.

The objective of our study was to determine the rate of intrauterine device (IUD) expulsion and risk factors for expulsion among adolescents and young adults. Retrospective chart review. IUD insertions were performed at a single children's hospital. Eligible adolescent and young adult patients who underwent IUD insertion between August 2009 and March2019. IUD insertion. Primary outcome was the incidence of IUD expulsion in adolescents and young women. Secondary outcomes were risk factors for IUD expulsion including heavy menstrual bleeding, abnormal uterine bleeding (AUB), anemia, or a bleeding disorder diagnosis. Six hundred forty-two eligible patients underwent IUD insertion. The incidence of first IUD expulsion in this population was 58/642 (9.03%). Among those who chose to have a second IUD placed (n=29), 8/29 (27.6%) had a second expulsion. Patients who expelled their IUD were more likely to have a history of AUB, heavy menstrual bleeding, anemia, or a bleeding disorder. When controlled for body mass index and age at insertion, history of AUB and anemia remained significant risks for IUD expulsion. This study similarly showed a higher risk of primary and secondary IUD expulsion in adolescents and young women. A history of AUB, anemia, bleeding disorder, and elevated body mass index are associated with higher risk for IUD expulsion. This population should be counseled that these conditions might place them at higher risk for expulsion.

Transcervical Tissue Extraction at the Time of Laparoscopic Myomectomy

Study Objective To demonstrate a minimally invasive myoma tissue extraction technique following laparoscopic myomectomy in a patient with a dilated cervix. Design Surgical video. Setting Surgery occurred in an academic medical center. The patient was placed in dorsal lithotomy position. A uterine manipulator was used. Patients or Participants A 33-year-old nulligravida presented to the office with a 9-month history of abnormal uterine bleeding and pelvic pain, unimproved by medical management and abdominal myomectomy performed 6 months prior. She had required multiple blood transfusions since surgery. She was using enoxaparin due to an active DVT. On examination, her uterus was 19 weeks in size and the cervix was 1.5cm dilated around a 6cm intracervical fibroid. MRI revealed multiple Type 1 and 2 fibroids. Interventions On laparoscopy, an incision was made on the uterine fundus and carried down to the endometrium, which was intentionally opened to reveal numerous submucosal fibroids. Working from the fundus to cervix, fibroids were successively enucleated. Eventually, the aborting cervical fibroid was laparoscopically extracted. Several fibroids were then removed via transcervical extraction. A laparoscopic tenaculum was passed through the dilated cervix and into the abdominal cavity through the hysterotomy. Fibroids were sequentially transferred to the transcervical instrument and extracted intact through the cervix. A total of 16 fibroids were removed and the myometrium was closed in 3 layers. A Foley catheter was placed in the endometrial cavity. Measurements and Main Results Uterine Foley was removed on POD#7. Two weeks after surgery, the patient reported significant improvement in bleeding and pain. Hemoglobin rose from 8.3 (POD#1) to 9.5. Conclusion Laparoscopic myomectomy is an alternative to hysteroscopic myomectomy in cases of numerous or large submucosal leiomyomas. Our transcervical tissue extraction technique saves operative time when both a dilated cervix from a prolapsing fibroid and extensive submucosal disease are present.

Use of Transcervical Radiofrequency Ablation for Treatment of Uterine Fibroids

Study Objective The purpose of this video is to demonstrate the use of transcervical radiofrequency ablation (RFA) of uterine fibroids utilizing the Sonata Procedure. Design Case presentation Setting Academic affiliated community hospital Patients or Participants 51yo G5P4, with a history of abnormal uterine bleeding and fibroids, who previously underwent abdominal myomectomy and presented for further management. After thorough counseling, patient opted for the Sonata procedure. Interventions The Sonata device was deployed to the targeted ablation zone and radiofrequency energy was applied to a goal temperature of 105 degrees Celsius. Complete ablation of a type II anterior fundal uterine fibroid was achieved without any complications. Measurements and Main Results Patient tolerated the procedure well. She was discharged approximately 2 hours after her procedure. She did not require any narcotic pain medications upon discharge. Conclusion Transcervical radiofrequency ablation is a safe and effective alternative treatment option for management of uterine fibroids. It should be considered in patients who wish to avoid major surgery or are poor surgical candidates.

An incidental case of uterus didelphys and fibroids: Right sided myomectomy and left hemi-hysterectomy

Congenital anomalies of the uterus occur due to agenesis or lack of fusion of the Mullerian ducts. The incidence of these anomalies is largely unknown since they are unlikely to be diagnosed in asymptomatic women. Uterine didelphys or double uterus occurs when the two Mullerian ducts fail to fuse resulting in duplication of the uterus and cervix. This report discusses a case of a 38-yearold woman who had presented with a longstanding history of abnormal uterine bleeding and cyclical pain. She had had two successful vaginal deliveries prior to presentation to our unit. Sonographic findings revealed large uterine myomas and was consented for open myomectomy. Intraoperatively she was found to have two uteri, both of which had intramural fibroids and two cervices.&#x0D; Keywords: didelphys uterus, fibroid.

Andlsquo;Endometrial Cancer: Access Deniedandrsquo; - A Review of the Forgotten Voice of Intellectual and Physical Disability in Gynaecology Oncology in Australia

Introduction: The voice of an intellectually and physically disabled woman is often forgotten when discussing, investigating and managing endometrial cancer in women with disabilities. This case report explores the need to start strategies for collaborative application of resources to optimize a woman’s experience who is living with disabilities and endometrial cancer. Case Description: A 41-year old premenopausal woman with a severe intellectual disability and physically debilitating osteogenesis imperfecta presented with a 2-year history of abnormal uterine bleeding (AUB) and unsuccessful hormonal treatment. After two failed hysteroscopies due to her severe bony-pelvic abnormality, limiting access vaginally; the decision for a hysterectomy was made without a histological diagnosis. An Australian Guardianship Tribunal granted permission for both diagnostic and treatment of her AUB and suspicion of endometrial cancer. The ESMO-ESGO-ESTRO-2014 Consensus current recommendations and levels of evidence in management of endometrial cancer are evaluated in context of the case. Method: Mandatory workup and pathological assessment for diagnosis of endometrial cancer could not be carried out and imaging including: CT scan, transabdominal ultrasound and MRI were relied upon to primarily assess her suspected disease. An abdominal hysterectomy, bilateral salpingectomy and ovarian conservation were performed. The histopathology post-operatively confirmed stage 1A grade 1 endometrioid adenocarcinoma. The time from initial Gynaecology Oncology referral to final histopathology was 9 months. Discussion: This is the first report to explore the limitations and challenges of the literature and application of various current diagnostic modalities, surgical approach and outcomes of endometrial cancer in an intellectually and physically disabled woman in Australia.

58: Vaginal approach to hysterectomy with uterine didelphys and longitudinal vaginal septum

Incidence of uterine malformations is 4.3% (Grimbizis, '01). Uterine Didelphys, AFS classification class III, represents 11% of all malformations. It results from failed fusion of paired mullerian ducts and is characterized by two separated uterine horns, each with an endometrial cavity and uterine cervix. A longitudinal vaginal septum usually runs between the two cervices (Heinonen, '84). There are case reports of laparoscopic and abdominal approaches to hysterectomy. A vaginal approach to hysterectomy for women with major congenital anomalies, specifically Uterine Didelphys has not yet been described. This case report represents a 39 year old Gravida 3 para 0 with a history of abnormal uterine bleeding and dysmenorrhea, secondary to endometriosis who failed medical management. On laparoscopic survey of the abdomen, a didelphic uterus was observed. The vaginal portion of the procedure was initiated, a longitudinal vaginal septum was outlined, demarcated, and dissected away from the urethra and bladder. Both cervices were then easily visualized and grasped with a Lahey tenaculum, circumscribed cervix anteriorly and posteriorly creating the vesicovaginal and rectovaginal spaces. Posterior peritoneal reflection was identified and entered sharply. The Uterosacral ligaments, uterine artery and cardinal ligaments were cut, clamped and suture ligated. The uterine fundus, fallopian tube and utero-ovarian ligaments on the right were cut, clamped, suture ligated and delivered and repeated on the left side. Posteriorly, the uterosacral ligament was plicated in the midline and the anterior vaginal wall was closed. Cystoscopy and post-operative course was uncomplicated, patient discharged on post op day 1. Uterine didelphys is a rare phenomenon; traditionally hysterectomy has been approached abdominally or laparoscopically. Vaginal approach to hysterectomy is a safe and feasible alternative.

Postmenopausal pregnancy? Evaluation of elevated hCG in a 59-year-old woman

Slightly elevated serum human chorionic gonadotropin (hCG) can be a normal finding in postmenopausal women. We report a case of a 59-year-old woman with a history of abnormal uterine bleeding...

Hysterosonography and Transvaginal Ultrasonography for Detection of Intrauterine Lesions in Women with Abnormal Uterine Bleeding

&lt;p&gt;Abnormal Uterine bleeding (AUB) is one of the frequent complaints of female patients of all ages. AUB is present in 33% of women referred to gynecologists and this increases to 69% in perimenopausal and postmenopausal women. About 10 % of postmenopausal bleeding results from endometrial cancer and imaging is the mainstay for its identification. Imaging plays a vital role in differentiating structural lesions like endometrial carcinomas, myomas and polyps which require surgical management from functional disorders requiring medical management. Transvaginal Ultrasonography (TVUS) is the first line imaging modality for AUB after selecting the patients with inconclusive pelvic ultrasonographic results. Hysterosonography (HSG) also plays a pivotal role.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objectives&lt;/strong&gt;&lt;strong&gt;:&lt;/strong&gt; To compares between TVUS and HSG in the detection and identification of intrauterine lesions in patients with abnormal uterine bleeding, and comparing the sensitivity and specificity of the respective methods in the detection of such lesions.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt; Thisstudy was conducted in Department of Radiology, Mayo Hospital Lahore. Fifty women presented with history of abnormal uterine bleeding were included in this study. Pregnancy was ruled out by transabdominal scan. Transvaginal ultrasound and hysterosonography were performed in all the patients. All the data were coded and analyzed using SPSS version 20.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Out of 50 patients, 10 patients had intramyometrial fibroid, 11 had submucosal fibroid, endometrial polyp was found in 17 patients and 2 patients had thickened endometrium (thickness &amp;gt; 8mm). The sensitivity and specificity of TVUS was found to be 83.2% and 82.7% respectively whereas HSG showed sensitivity and specificity of 95.4% and 91.5% respectively. In the detection of the submucosal fibroid and endometrial polyp, HSG showed highest sensitivity and specificity as compared totransvaginal ultrasound.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;Both the TVUS and HSG have comparable sensitivity and specificity in the detection of endometrial disease in patients presented with abnormal uterine bleeding however HSG is more sensitive in the detection of polyps.&lt;/p&gt;

Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient: Role of a Novel NQO1*2 Polymorphism.

Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results—including coagulation parameters—were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient’s warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient’s international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S) polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.