Premenopausal Woman Research Articles

Myocardial infarction in a premenopausal woman with a decreased serum estrogen level due to leuprorelin acetate

A 45-year-old premenopausal woman was admitted with acute myocardial infarction. Her serum estrogen level was decreased because of leuprorelin acetate administration, 3 months prior to admission for the treatment of uterine myoma. Emergency coronary angiography revealed diffuse narrowing of the distal half of the left anterior descending artery (LAD). The second coronary angiography after anti-anginal medication revealed significant improvement in LAD narrowing, which suggested prolonged coronary vasospasm. She had no coronary risk factors except for a positive family history. This case suggests that a decreased serum estrogen level could cause ischemic heart disease even in premenopausal women.

A propósito de un caso: falso positivo en pelvis en un estudio PET-TAC debido a una reimplantación ovárica

We present the case of a 36-year-old premenopausal woman with a background of surgically-treated cervical neoplasm. She underwent a positron emission tomography-computed tomography (PET-CT) for evaluation of the new appearance of abnormal inguinal lymph nodes. The study showed two hypermetabolic nodules in the pelvic region suggestive of corresponding to an implant and to tumor involvement of the lymph node, respectively. After a clinical evaluation and a new PET-CT scan, it was considered that these uptake foci corresponded to physiological activity of the FDG secondary to ovarian activity in a patient with ovariopexy. This article shows the importance of having complete clinical information about the patients before evaluating the studies. We also present a review of the medical literature on the cervical neoplasm and metabolic behavior of the adnexa in relationship with the menstrual cycle of pre-menopausal women.

Laparoscopic repair of spontaneous vaginal evisceration of small bowel: report of a case

Spontaneous vaginal evisceration of the small bowel is a rare event. It is precipitated in the postmenopausal woman commonly by hysterectomy and in the premenopausal woman by vaginal trauma. We report a case of a 75-year-old woman presenting with a protruding mass in her vagina and associated abdominal pain. A combined laparoscopic and transvaginal method of repair is described and the advantage of using both techniques highlighted.

False positive in pelvis in a PET-CT scan due to ovarian reimplantation: A case report

We present the case of a 36-year-old premenopausal woman with a background of surgically-treated cervical neoplasm. She underwent a positron emission tomography-computed tomography scan (PET-CT scan) for evaluation of the new appearance of abnormal inguinal lymph nodes. The study showed two hypermetabolic nodules in the pelvic region suggestive of corresponding to an implant and to tumor involvement of the lymph node, respectively. After clinical evaluation and a new PET-CT scan, it was considered that these uptake foci corresponded to physiological activity of the FDG secondary to ovarian activity in a patient with ovariopexy. This article demonstrates the importance of having complete clinical information about the patients before evaluating the studies. We also present a review of the medical literature on the cervical neoplasm and metabolic behavior of the adnexa in relation to the menstrual cycle of premenopausal women.

Successful Magnetic Resonance Imaging‐Guided Focused Ultrasound Surgery for Recurrent Uterine Fibroid Previously Treated with Uterine Artery Embolization

A 45-year-old premenopausal woman was referred to our clinic due to recurring symptoms of uterine fibroids, nine years after a uterine artery embolization (UAE). At the time of screening, the patient presented with bilateral impairment and narrowing of the uterine arteries, which increased the risk of arterial perforation during repeated UAE procedures. The patient was subsequently referred for magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) treatment. Following the treatment, the patient experienced a significant improvement in symptoms (symptom severity score was reduced from 47 to 12 by 1 year post-treatment). MR images at 3 months showed a 49% decrease in fibroid volume. There were no adverse events during the treatment or the follow-up period. This case suggests that MRgFUS can be an effective treatment option for patients with recurrent fibroids following previous UAE treatment.

Reversible posterior leucoencephalopathy syndrome associated with anticancer drugs

Reversible posterior leucoencephalopathy syndrome (RPLS) is an underappreciated clinical-radiologic syndrome characterized by reversible cortical dysfunction preferentially involving the occipital lobes in conjunction with imaging findings of reversible subcortical oedema. As RPLS is being increasingly identified within the oncology population in association with cytotoxic chemotherapy and targeted agents, a review of the published work in English was carried out. A MEDLINE search of the published work in English was conducted to identify cases of RPLS in patients more than 16 years of age who were treated with anticancer drugs for documented malignancy. Only cases with adequate documentation regarding demographic and treatment data, cerebral magnetic resonance imaging and outcome were selected. We identified 24 patients with RPLS associated with a variety of anticancer drugs, most commonly complicating polychemotherapy and/or bevacizumab-containing regimens. There was a female predominance: 18 females and 6 males (P= 0.023). Women were of premenopausal age and were younger than males: 49.3 +/- 16.4 years versus 60.7 +/- 6.4 years (P= 0.09). Most patients presented with acute headache (67%), seizures (63%), confusion (54%) or cortical blindness (46%) with mean systolic and diastolic blood pressure of 168 +/- 15 and 98 +/- 15 mm Hg, respectively. Findings on magnetic resonance imaging showed hyperintense lesions on T(2)-weighted images in all patients, which involved the occipital lobes in 75% of patients; all patients experienced clinical and radiologic resolution within days to weeks. No deaths were directly attributed to RPLS. Combination and single-agent chemotherapy as well as novel anticancer drugs are associated with RPLS. We found RPLS to be overrepresented in premenopausal woman; the prevalence in this subgroup may be related to an anticancer drug-oestrogen interaction inducing altered cerebral vasoreactivity and endothelial dysfunction.

Intracystic papillary carcinoma of the breast in a 21-year old premenopausal Nigerian woman: a case report

We report the case of a 21-year-old Nigerian woman who presented to us with features of intracystic papillary carcinoma, a rare form of breast cancer usually seen in postmenopausal women in their sixth to eighth decades of life. To the best of our knowledge, there has been only one other case report of this lesion occurring in women in their second decade of life.Physical examination showed a well-defined mass, 54 mm in diameter, in the upper proximal quadrant of the right breast close to the areola, histologically composed of monotypic epithelial cells disposed in solid, cystic, and papillary patterns. A diagnosis of intracystic papillary carcinoma was made because of the presence of intracystic arborization of the fibrovascular stroma, a monotonous cell population, the presence of mitoses, and the lack of myoepithelial cells determined by immunohistochemistry using calponin and p63 stains. Estrogen receptor status was positive while progesterone status and HER-2-neu receptor status were negative.The patient has survived for 12 months without any sign of recurrence after the last surgical resection of the tumor.

Lymphangioleiomyomatosis: solitary abdominal manifestation (2009: 9b)

Lymphangioleiomyomatosis (LAM) is a rare disease that usually affects premenopausal woman and is characterized by cystic lung lesions and lymphatic disorders. We report a case of a 23-year-old woman who presented with diffuse, but increasing abdominal pain. Transabdominal ultrasound showed multiple cystic formations. Due to the patient's uncharacteristic symptoms, an exploratory laparotomy with tissue sampling was performed, and the diagnosis of LAM was confirmed by two independent pathologists. With computed tomography a broad abdominal, but no pulmonary, manifestation could be established. During sirolimus therapy the patient showed clinical benefit, but only slight progress in computed tomography.

Un cas d’actinomycose mammaire primitive à Actinomyces neuii

Primary actinomycosis of the breast is a rare disease, with only 32 cases reported in the literature since 1893. The diagnosis is done in front of a recurrent abscess with fistulas and purulent discharge. Bacteriologic analysis only can confirm the diagnosis. We report the first case of primary actinomycosis of the breast caused by Actinomyces neuii, in a 46-year-old premenopausal woman. No cause of this condition was reported. Targeted antibiotic therapy did not improve the condition. A tumorectomy of the breast was decided. Six months after surgery, no recurrence has been observed.

Choriocarcinome avec atteinte pulmonaire : stratégie diagnostique et thérapeutique

Choriocarcinoma is a rare tumour which results from the anarchic proliferation of a gonadic or extra gonadic germinal cell. A 45 year old pre menopausal woman of African origin presented with a persistent cough and deterioration of general status. The chest X-ray revealed a cavitated mass of the right upper lobe. Other lesions were associated (liver, kidney and scalp). Choriocarcinoma, suspected in the presence of an elevated ssHCG without a gravid uterus, was confirmed by biopsy excision of a haemorrhagic cutaneous lesion of the scalp. Despite the poor prognosis methotrexate based chemotherapy resulted in control of the disease and a good remission.

Uterine Fibroid Embolization

A 45-year-old, premenopausal black woman (gravida 3, para 2, with a history of one spontaneous abortion) presents with menorrhagia and dysmenorrhea that has worsened progressively over a period of 10 years. She does not wish to have any more children. On physical examination, she has a firm, nontender, enlarged uterus. The ovaries are not palpable. Laboratory tests in the past had revealed intermittent mild anemia that was correctable with iron supplementation, but more severe anemia has been noted recently, and she has had increasing difficulty managing her menstrual bleeding. In-office ultrasound examinations have shown several intramural uterine masses consistent with uterine fibroids that have been slowly increasing in size; the largest measures 6.5 cm at the point ofits greatest dimension. The adnexa are normal. The patient's gynecologist has recommended a hysterectomy. However, the patient does not want to undergo a hysterectomy, and her gynecologist suggests uterine fibroid embolization as an alternative. She is referred to an interventional radiologist who orders a magnetic resonance imaging (MRI) scan. The results ofthe MRI confirm the ultrasound findings and rule out adenomyosis. The interventional radiologist discusses with the patient uterine fibroid embolization as an alternative to hysterectomy. What treatment should be recommended for this patient?

Martius Graft for the Management of Tension-Free Vaginal Tape Vaginal Erosion

The tension-free vaginal tape (TVT) procedure has become standard for the treatment of stress urinary incontinence in women. The procedure carries a risk of vaginal erosion and exposure of the mesh. When this occurs, most surgeons recommend removal of the tape for immediate relief of symptoms. However, this poses a risk of recurrence of urinary incontinence. A premenopausal woman had an exposed vaginal mesh after a TVT procedure. After failed conservative treatment, she was treated successfully using a Martius graft, with preservation of the mesh. The Martius procedure was a practical alternative for treating this patient with synthetic-mesh-induced vaginal erosion. It allowed preservation of the sling, thereby preventing recurrence of urinary incontinence.

Mastopathic-type fibroadenoma and ductal adenoma of the breast with false-positive fluorodeoxyglucose positron emission tomography

Positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) has been shown to be an effective and accurate diagnostic technique for breast cancer. However, benign breast lesions have also been reported to show a false-positive FDG uptake on PET. We present two cases of benign tumors that revealed FDG uptake on PET and were difficult to distinguish from breast cancer. A 46-year-old premenopausal woman noticed a mass in her right breast. Ultrasonography showed a hypoechoic mass with the size of 7.7 x 3.9 mm and an irregular shape in the right breast. PET demonstrated a focal accumulation of FDG with a maximum standardized uptake value (SUVmax) of 2.1. Excisional biopsy was performed, and ductal adenoma was diagnosed. In the second case, a 36-year-old premenopausal woman was pointed out as showing an abnormality in the left breast on screening mammography. Ultrasonography showed a hypoechoic mass of 1.5 x 1.2 cm in size in the left breast. The lesion was depicted as a mass with prominent enhancement on dynamic CT and a focal accumulation of FDG with SUV max of 3.5 on PET. It was diagnosed as fibroadenoma of mastopathic type histopathologically by excisional biopsy. The readers should be aware that these benign tumors may cause false-positive results on PET.

Eleven years disease-free: role of chemotherapy in metastatic BRCA2-related breast cancer

Infiltrating ductal carcinoma of the breast, staged as pT1N3, was diagnosed in a 41-year-old premenopausal French-Canadian woman. Rapid nodal recurrence progressed to diffuse bone metastases, despite tamoxifen and megestrol. Following enrollment in an in-house study protocol, she received high-dose anthracycline-based induction chemotherapy followed by tandem autologous bone marrow transplantation with high-dose alkylator and platinum-based conditioning regimens. Upon full remission, protocol-mandated locoregional breast and prophylactic cranial radiation was delivered. Complete clinical and radiologic remission has been maintained in the 11 years since study enrolment, which prompted further investigation. Pedigree construction and BRCA1/2 mutation analysis. A BRCA2 8765delAG mutation was identified, in the context of unusual and sustained complete remission from widely metastatic breast cancer. The patient is now followed at a multidisciplinary high-risk prevention clinic because BRCA2 mutations are associated with increased risk of ovarian and breast cancers. This case supports the possibility of differential treatment response in BRCA2-positive breast cancer, although this remains to be conclusively demonstrated.

Urinothorax

Urinothorax is defined as the presence of urine in the pleural cavity. This condition is due to the leakage of urine from the peritoneal and retroperitoneal space into the pleural space. We report a case of urinothorax after total abdominal hysterectomy. A premenopausal woman underwent total abdominal hysterectomy and left salpingo-oophorectomy for pelvic pain, requiring extensive dissection. Her postoperative course was complicated by right urinothorax, which was diagnosed after a diagnostic thoracocentesis and resolved after a therapeutic thoracocentesis and the repair of the urinary bladder rent. Urinothorax can occur in cases of undiagnosed urinary tract injury. It presents as postoperative shortness of breath and pleural effusion and should be considered in the differential diagnosis.

Analytical and Biological Variation of F2-Isoprostanes during the Menstrual Cycle

F2-isoprostanes have been advocated as a specific and reliable marker of oxidative damage (1) despite a lack of data on their biological and analytical variation. Concurrent with a longitudinal study of oxidative stress during the menstrual cycle [the BioCycle Study(2)], we have characterized the components of biological and analytical variation of free plasma F2-isoprostanes in the context of the menstrual cycle. We describe several of the key characteristics of F2-isoprostanes as a biomarker. Samples were collected from 9 healthy volunteers who met the major inclusion criteria of being a premenopausal woman 18–44 years of age and having regular menstrual cycles. Major exclusion criteria included use of hormonal preparations or contraceptive devices, pregnancy, a history of gynecologic abnormalities, recent infectious disease, routine intake of prescription and over-the-counter medications (including vitamin and mineral supplements), and a history of certain chronic diseases or conditions. Fasting blood samples were collected between 0700 and 0830 on days 2, 7, 12, 13, 14, 18, 22, and 27 of a single menstrual cycle. Collection and handling protocols were designed to minimize preanalytical variation. Samples were frozen at −80 °C and then analyzed, in duplicate, as a single set of consecutive samples by GC-MS (1) at the Molecular Epidemiology and Biomarker Research Laboratory at …

Renal endometriosis presenting with a giant subcapsular hematoma: case report

To describe a case of renal subcapsular hematoma due to renal endometriosis. Case report. Departments of Urology and Pathology, Baskent University Faculty of Medicine, Ankara, Turkey. A 46-year-old premenopausal woman was admitted with a left lumbar pain and mass. Ultrasonography and computerized tomography revealed a giant-sized renal subcapsular hematoma. Computerized tomography, percutaneous drainage catheter placement, surgical exploration, and excision of renal capsule. None. Histopathologic examination revealed endometriosis located beneath the fibrous renal capsule. Renal capsular endometriosis should be kept in mind among the causes of renal subcapsular hematoma.

P0559 INFECTIOUS ENDOCARDITIS OVER 10 YEARS IN AN INTERNAL MEDICINE DEPARTEMENT

parasitic and mycotic infections), malignancy (breast carcinoma) and other causes of granulomatous disease (as sarcoidosis, Wegener’s granulomatosis, giant cell arteritis or polyarteritis nodosum). Case report: A 38-year-old pre-menopausal woman presented with a twoweek history of a left breast mass. She had no particular medical records, there was no history of oral contraceptive use and she breastfed her 3-year-old child for 16 months. Concerning family illness, she had two aunts affected with breast cancer. The woman was apyretic and on physical examination there was a hard and painful mass, with 10cm diameter, on her left breast. The overlying skin showed signs of inflammation, and a 2cm palpable lymph node was present in the ipsilateral axilla. She began therapy with a broad spectrum antibiotic, which showed no success in resolving the lesion. Radiologic data was suggestive of a malignant process. Fine needle aspiration cytology was performed, as well as a skin, breast and lymph node biopsy, but the histopathologic results were inconclusive. Therefore, a wide excision was done, which revealed an inflammatory nonspecific mastitis with all microbiology and serological tests being negative. She was than treated with prednisone 60mg, gradually tapered in 6 weeks, and after 1 year had no recurrence. Conclusion: IGM is a rare and benign inflammatory process, commonly mistaken for malignancy and consequently can lead to unnecessary surgical procedures. Correct diagnosis requires the exclusion of malignancy, other granulomatous disease and infectious etiologies, combined with definitive histopathological confirmation. There is no clear clinical consensus regarding the ideal therapeutic management of IGM, but corticoid therapy should be an option.

Endometrioid endometrial adenocarcinoma in a premenopausal woman with multiple organ metastases

Endometrial adenocarcinoma is the third common malignancy of the female genital tract occurring most often in the postmenopausal age group. High tumor grade, advanced surgical stage, and lymphovascular space invasion are implicated as poor prognostic factors for dissemination of disease. We present an unusual case of endometrial adenocarcinoma in a premenopausal woman with simultaneous metastases in brain, liver, skin and skeletal system, within one month of completion of treatment. The role of adjuvant/concurrent chemotherapy in addition to radiotherapy in high risk cases is discussed along with the review of literature.

Hysterectomy – a life-saving as well as a life-enhancing operation?

Hysterectomy with or without oophorectomy continues to receive a bad press in lay magazines as well as professional journals when the facts belie such a judgement. Hardly an article fails to inform the public that the operation commonly results in depression, loss of libido, anxiety and marital problems when in most cases and virtually all studies the opposite is true. It is clearly understood that the surgery should be performed competently for the appropriate indications of distressing cyclical symptoms of bleeding, pelvic pain, depression, PMS and fatigue possibly with co-existent fibroids, PID or endometriosis. These women who may only have had a few good days a month should have their life transformed by the surgery with appropriate hormone replacement. Frequently, their one regret is that it was not performed years earlier. With correct selection, the life-enhancing effect is no longer debatable but the lifesaving claim is less accepted but equally logical. Between 3% and 4% of women per year, about 5000, in the UK die of cancer of the ovary, cervix or endometrium including a small number with sarcoma. There will be the rare occurrence of ovarian/peritoneal tumours after oophorectomy but that does not diminish the argument if it is indeed valid. Endometrial cancer is becoming more common due to increasing age and obesity, ovarian cancer is increasing slightly and an increase in cervical cancer is occurring particularly in the less well-screened immigrant population. There is of course a mortality associated with the surgery usually calculated as one in 3000 but if the 3–4% figure is correct, the mortality of not doing the operation is about one in 35 although these deaths will occur later in life. Such a comparison expressed in this way may be deeply shocking and to many an unacceptable and unpalatable deduction. But it is hard to refute. This is not to suggest a stampede out to perform prophylactic hysterectomies and oophorectomies in asymptomatic women with no complaints and who have a natural desire to keep their organs, but it is a plea that the many women who suffer distressful gynaecological symptoms for most of the month are given the chance of curative surgery, which is not seen as a treatment of last resort after years of failed medical and hysteroscopic treatment. However, the key to this discussion is the benefits or risks of long-term hormone replacement in these premenopausal women. Much media attention was given to the meta-analysis showing that hysterectomy and bilateral oophorectomy was associated with more heart attacks, more strokes and a shorter life-expectancy. The dangers of a premature menopause on the cardiovascular system have been known for about half a century, but still it is possible to read such publications reporting the effect of an early surgical menopause with no women receiving replacement estrogens. This is unsatisfactory clinical practice. Such data should not be used to form any opinion about the merits of surgery although it speaks volumes about unacceptable after care. It should be clear that a surgeon should not remove the ovaries in a premenopausal woman without prescribing appropriate replacement therapy otherwise the operation is as incomplete as a hysterectomy with the gynaecologist omitting to close-up the wound. Such treatment must be seen as palpably substandard. But even so there are commentators who miss the point that the cause of any increased long-term morbidity of this surgery is a failure to replace the missing hormones. HRT like any effective treatment has side-effects but the serious problems appear to be a result of the progestogen component, which is not necessary after a hysterectomy. The estrogen-only arm of the WHI study showed a 28% decrease in breast cancer (0.43–1.07), a 42% decrease in heart attacks (0.3–1.03) and a 27% decrease in mortality (0.47–1.13) in women who stated HRT under the age of 60. These apparent considerable benefits were not significant but what sort of conspiracy or incompetence led to the premature closure of this study at this point. That should be a topic for a future editorial. The profession and the public should reconsider their hostility to a well-performed hysterectomy for appropriate indications followed by safe HRT. The operation performed in women with severe menstrual, emotional symptoms can be life changing and should not be delayed on doctrinaire grounds. It is also clear that removal of the ovaries in premenopausal women must, unless there are Menopause International 2009; 00: 1–2. DOI: 10.1258/mi.2009.009009