Submucosal Myomas Research Articles

Treatment of perimenopausal menorrhagia in women with scarred uteri and submucosal myomas using thermal balloon with and without GnRH analog pretreatment

Treatment of perimenopausal menorrhagia in women with scarred uteri and submucosal myomas using thermal balloon with and without GnRH analog pretreatment

Immediate versus delayed treatment of perimenopausal bleeding due to benign causes by balloon thermal ablation

To compare the effectiveness and safety of thermal balloon ablation without pretreatment with endometrium-thinning agents compared with delayed ablation with pretreatment for women with perimenopausal menorrhagia. Prospective, randomized, controlled trial (Canadian Task Force classification I). Hospital-based ambulatory medical center. Thirty women age 46 to 51 years with severe enough perimenopausal menorrhagia to make them candidates for either hysterectomy or endometrial ablation. Two patients with submucosal myomas and six who had undergone cesarean section were included. Thirteen patients were randomly assigned to be treated within 30 days and received a single intramuscular administration of gonadotropin releasing hormone (GnRH) analog; 17 women were allocated to be treated within 3 days of enrollment without uterine preparation. A thermal balloon was inserted transcervically under general anesthesia, and after inflation in the endometrial cavity with 5% dextrose in water, was heated to 87 degrees C for 8 minutes. Immediate and long-term major and minor complications and success rates were analyzed. Bleeding patterns and mean duration of menstrual flow were compared between groups at 6-month follow-up. No major intraoperative or postoperative complications occurred in either group, including the women who had recently undergone hysteroscopic myomectomy or had a history of cesarean section. Minor side effects were similar in both groups, and did not exceed 5%. Overall, at 6-month follow-up, 7 women were amenorrheic, 20 hypomenorrheic, and 3 eumenorrheic. No significant differences were noted between women treated with immediate or delayed ablation in either the distribution of bleeding patterns or days of flow per cycle (mean +/- SEM 1.8 +/- 0.42 vs 2.1 +/- 0.75 days, respectively). This pilot study suggests that prompt treatment of perimenopausal menorrhagia with thermal balloon endometrial ablation is as effective and safe as deferred therapy combined with GnRH analog as an endometrium-thinning agent. In light of our results, the theory that previous cesarean section and presence of small submucosal myomas constitute relative contraindications for the procedure merits further consideration. (J Am Assoc Gynecol Laparosc 6(2):145-150, 1999)

Utilizing Routine Sonohysterography to Detect Intrauterine Pathology Before Initiating Hormone Replacement Therapy

To assess the utility of performing routine sonohysterography in conjunction with endometrial thickness measurement for detecting intrauterine pathology in asymptomatic postmenopausal women. Asymptomatic postmenopausal women (n = 60, mean age 52.7 +/- 4.5 years, amenorrhea > or = 6 months, follicle stimulating hormone > or = 40 mIU/mL) were evaluated with sonohysterography followed by endometrial biopsy before initiating hormone replacement therapy. Hyperplasia was detected in 5 of 22 (22.7%) patients with endometrial thickness of > 5 mm and in 0 of 38 (0.0%) patients with endometrial thickness of < or = 5 mm. When sonohysterography was performed, intracavitary pathology was discovered in 14 of 38 (36.8%) patients with endometrial thickness of < or = 5 mm (10 polyps, three submucosal myomas, and one septate uterus) and 14 of 22 (63.6%) patients with endometrial thickness of > 5 mm (nine polyps, four submucosal myomas, and one Asherman's syndrome). Endometrial thickness of < or = 5 mm excludes hyperplasia but does not eliminate other intrauterine pathology that may be discovered by sonohysterography.

Endoscopic management of uterine myoma.

This study was undertaken to evaluate the various gynecologic endoscopic surgical techniques including resectoscopic myomectomy, laparoscopic myomectomy, and laparoscopy assisted vaginal hysterectomy (LAVH) used in the treatment of uterine myomas. The medical records of 136 cases of uterine myomas treated using one or more of the gynecologic endoscopic surgical techniques in the Department of Obstetrics and Gynecology at Yonsei University were retrospectively reviewed from March 1997 to September 1998. Of the 136 cases reviewed, there were 40 submucosal myomas and 96 intramural and subserosal myomas. For statistical analysis, Student's t-test was used. Submucosal myomectomy using the resectosope was performed in 35 cases (mean age: 39 +/- 1.5 years), laparoscopic myomecotmy in 35 cases (mean age: 36 +/- 1.9 years), and LAVH in 66 cases (mean age: 42 +/- 1.1 years). In cases of huge myomas, the GnRH agonist was used prior to surgery, and in cases of heavy uterine bleeding, angioblock of the uterine artery was undertaken before the endoscopic procedures. The mean operating time was significantly shorter in resectoscopic myomectomy (41 +/- 12 min), followed by laparoscopic myomectomy (85.0 +/- 10.3 min) and LAVH (123 +/- 5.3 min). The mean hospital stay for resectoscopic myomectomy, laparoscopic myomectomy, and LAVH was 1.9 +/- 0.5, 2.5 +/- 0.5, and 3.4 +/- 0.8 days (p < 0.001), respectively. There were 3 cases of complications including pulmonary edema and uterine perforation in the resectoscopic myomectomy group, and 4 cases of complications including bladder, ureter, and epigastric vessel injury in the LAVH group. In conclusion, the therapeutic effect of various gynecologic endoscopic surgical techniques can be maximized in terms of shorter operation time, shorter hospital stay, faster recovery, and less blood loss by the appropriate management of uterine myoma in well-chosen patients.

Upper genital-tract screening with hysterosonography in patients receiving donated oocytes

Objective: To compare the results of sonohysterography (SHG) for imaging of the uterine cavity to hysterosalpingogram (HSG) and hysterscopy (HSC) in order to assess its clinical utility for recipients of donated oocyte. Method: From January 1996 to December 1996, we evaluated all patients ( n = 50) referred for ovum donation using SHG and compared the results with HSG obtained within 6 months of SHG. Patients having either an abnormal SHG of HSG underwent HSC for confirmation and treatment. SHG was routinely performed during the early follicular phase using 10 cc saline instilled through an intracervical H-S catheter with concurrent vaginal sonography. Result: Pathology was observed and confirmed in 19 cases (38%) including polyps ( n = 10, 52.6%), submucosal myomas ( n = 7, 36.8%), intrauterine adhesions ( n = 1, 5.3%) and bicornuate uterus ( n = 1, 5.3%). SHG and HSG were concordant in 46 cases (95.8%) of which in 29 (60.4%) a normal cavity was observed, while four studies (8%) did not agree. Two polyps were missed on HSG, while two SHGs incorrectly diagnosed a calcified myoma and an endometrial fold. Using HSC for definitive identification, the accuracy of SHG was 90%, and similar to HSG. Conclusion: SHG appears both sensitive and highly predictive for evaluating pathology of the endometrial cavity and appears to be as effective as HSG. Advantages of SHG include improved imaging or uterine pathology, cost, greater patient comfort and the avoidance of radiation. Routine SHG of recipients uncovered a high incidence of abnormalities in older women and underscores the need to evaluate the uterine cavity prior to ovum donation.

HYSTEROSCOPY: A MILESTONE IN GYNAECOLOGY

Objective The aim is to stress the fundamental role of hysteroscopy in the diagnosis of the cause of endometrial pathologies. Subjects and methods The results of 10 years’ experience, between December 1984 and January 1995, in the gynaecological endoscopy outpatients' unit of the Catholic University of Rome are reported. A series of 6180 women undergoing diagnostic hysteroscopy is analysed and the indications, contraindications and side‐effects of hysteroscopic examination are discussed. Results Outpatients, mean age of 51 years (range 22–81), who underwent hysteroscopic examination had, as main indication, abnormal uterine bleeding (AUB). The differing distributions of hysteroscopic findings in pre‐ and postmenopausal women is stressed, along with the importance of focal endometrial pathologies such as polyps and submucosal myomas in premenopause, the high incidence of endometrial atrophy, and the significant occurrence of hyperplastic and neoplastic hysteroscopic findings in the postmenopause. Primary and secondary infertility are, after AUB, the second most common indications for hysteroscopic examination, and the role of malformation (septate and subseptate uterus), inflammation (intrauterine synechiae) and focal endometrial pathologies (polyps and submucosal myomas) is illustrated. Conclusions As a result of the introduction of hysteroscopy it is now possible to preserve organs, with the slight trauma of noninvasive treatment, rather than using extirpartive surgery. In premenopausal women with AUB (n=2132) the most frequent pathologies were low‐risk hyperlasia (25.3%), submucosal myoma (24.5%) and endometrial polyps (8.3%); there were normal findings in 40.2%. There is a low incidence of high‐risk hyperplasia (0.7%) and neoplastic pathology (0.5%). In postmenopausal women with AUB there is a high incidence of atrophy (23%), whereas high‐risk hyperplasia and neoplastic pathology are five and eight times more common, respectively, in these women than in premenopausal patients.

Evaluation of patients with abnormal uterine bleeding

An accurate, efficient diagnosis of disorders responsible for abnormal uterine bleeding depends on a systematic consideration of all the possible causes. Careful history and physical and pelvic examinations provide the framework for evaluation. Many adjunctive diagnostic aids can be used to evaluate women with abnormal uterine bleeding. These tests include complete blood cell count, pregnancy test, hormone levels (estradiol, progesterone, follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone, dehydroepiandrosterone sulfate), thyroid function tests, liver function tests, and coagulation profile. The need for these tests are individualized and based primarily on the patient's presentation. In women of reproductive age a complication of pregnancy should always be ruled out. Ectopic pregnancies can be life threatening. The prognosis in women with trophoblastic disease can be altered by a delay in establishing the correct diagnosis. Ultrasonographic studies, particularly transvaginal ultrasonography and hysteroscopy, have played an increasing role in the evaluation of patients with abnormal uterine bleeding over the past decade, especially for cases of intrauterine space-occupying lesions, including endometrial polyps, submucosal myomas, and retained placental fragments. Suspicion of reproductive tract malignancies is heightened in patients >35 years old, those with a history of oligoovulation or anovulation suggestive of long-term unopposed estrogen exposure, those who are obese, and those who do not respond to first-line medical management. Diagnostic techniques available for the evaluation of these cases include endometrial biopsy, dilatation and curettage, transvaginal ultrasonography, and hysteroscopy. These procedures not only allow accurate diagnosis but may permit immediate therapeutic measures to be taken when organic causes are discovered. In summary, the key to the evaluation of abnormal uterine bleeding is a thorough history and physical and pelvic examinations governed by the differential diagnosis of excessive uterine bleeding and the selected use of adjunctive diagnostic tests and procedures only when absolutely necessary. (Am J Obstet Gynecol 1996;175:784-6.)

Endometrial evaluation in asymptomatic postmenopausal women by transvaginal sonography and color flow Doppler

We attempted to correlate transvaginal ultrasound endometrial assessment with histologic and hysteroscopic findings in 910 asymptomatic postmenopausal women. The women all had been postmenopausal for at least 1 year, and had no sonographically documented adnexal masses, no hormone therapy, and no history of uterine bleeding. Endometrial thickness of 5 mm and less was considered normal, and no further investigations were performed. All women with endometrial thickness 8 mm or greater were advised to undergo hysteroscopy and endometrial biopsy if necessary. When endometrial thickness was 6 to 7 mm, hysteroscopy was recommended if irregular endometrial echotexture was observed; otherwise another ultrasound examination within 3 to 6 months was suggested. We observed 83 (9.1%) asymptomatic women with endometrial thickness 8 mm or greater and 77 (8.5%) with a thickness of 6 to 7 mm, in whom a total of 89 hysteroscopies were performed. Three endometrial cancers, 8 hyperplasias, 27 endometrial polyps, and 5 submucosal myomas were detected in those with endometrial thickness of 8 mm or greater. Of the 21 women with endometrial thickness 6 to 7 mm who underwent hysteroscopy, 7 had endometrial polyps, 4 hyperplasia, and 3 submucosal myomas. Based on sensitivity and specificity analyses, an endometrial thickness of 8 or 10 mm in asymptomatic postmenopausal women seems to be an effective cut-off to select candidates for more invasive diagnostic procedures.

7 Treatment of dysfunctional bleeding and fibroids by advanced endoscopic techniques with the Nd: YAG laser: from the present to the future

Both the electrical current of the resectoscope and the energy of the Nd:YAG laser have been effective tools in the destruction of endometrial tissue to a sufficient depth to avoid regeneration. GnRH-agonist therapy effects a decrease in the total uterine cavity area which facilitates surgical treatment and reduces the risk of fluid overload syndrome. The recurrence rate of meno/metrorrhagia is higher when the uterine cavity is more than 10 cm2. The use of GnRH-agonists represents an adjunct for preoperative reduction of submucosal myomas so that subsequent hysteroscopic myomectomy is possible. A two-step hysteroscopic therapy combined with GnRH-agonist therapy is performed when the largest portion of the submucosal myoma is located in the uterine wall. In cases of numerous submucosal and intramural myomas, a laparoscopic supracervical hysterectomy is performed because of the high risk of recurrence after the hysteroscopic procedure.

Uterine rupture at 33 weeks' gestation subsequent to hysteroscopic uterine perforation

A 40-year-old woman underwent operative hysteroscopy for suspected submucosal myoma, during which the uterine fundus was perforated. At laparotomy the perforation site was sutured. In a subsequent pregnancy she had a sudden onset of abdominal pain. Laparotomy revealed a uterine rupture with a partially protruding placenta. A healthy newborn was delivered by a low-segment cesarean section. (AM J OBSTET GYNECOL 1994;170:786-7.)

Laparoscopic supracervical (subtotal) hysterectomy (LASH).

The use of laparoscopically assisted vaginal hysterectomy with or without annexectomy has been widely discussed. We report the technique of laparoscopic supracervical (subtotal) hysterectomy (LASH), which was first performed in 1990. Laparoscopic supracervical hysterectomy was carried out in a series of 36 women. The duration time was 60 min in experienced hands. There were no major complications. The feasibility and low morbidity rate of this laparoscopic approach led us to propose LASH in certain indications, particularly in cases of a uterus with multiple submucosal myomas where hysteroscopic therapy is less successful.

Endometrial sampling: When? Where? Why? With what?

Today, evaluating women with abnormal uterine bleeding generally is initiated in the office with an endometrial biopsy. The indications and contraindications for endometrial sampling along with situations which do not, per se, demand sampling are listed in Figure 1. In women younger than 40 years of age, it may be appropriate in some clinical situations to initiate hormonal therapy after an endocrine evaluation before endometrial sampling; however, with the newer sampling devices that cause minimal discomfort, a histologic evaluation can be performed easily. Furthermore, the endometrial biopsy may help to distinguish anovulatory from ovulatory bleeding and exclude a hyperplastic condition or carcinoma. If the patient does not respond to medical therapy, then hysteroscopy may identify endometrial polyps or submucosal myomas. Bleeding in postmenopausal women requires endometrial sampling. If a diagnosis of cancer can be made in the office, this will expedite treatment. For those cases in which, for technical reasons, it is impossible to do an office biopsy or in which an examination under anesthesia is necessary for evaluation, then a D&C is indicated. The refined technology of transvaginal ultrasonography and hysteroscopy in the future may influence more directly the evaluation of women with abnormal uterine bleeding. As noted, transvaginal ultrasonography may determine which women would benefit from an endometrial biopsy, both for symptomatic and asymptomatic women. Likewise, the hysteroscope, under certain circumstances, may help identify pathologic findings missed by endometrial biopsy and/or reassure the patient or physician that a negative biopsy is the result of an atrophic mucosa. Because of the increase in the use of hormonal therapy, both in postmenopausal women for replacement and in women with breast cancer as adjuvant therapy, endometrial sampling must be performed for screening. Follow-up for women with premalignant changes of the endometrium treated with hormones also would require sampling to assess response. The overwhelming arguments in favor of the accuracy of an office-based endometrial biopsy, the convenience to the patient and physician, and the cost containment have been established firmly in the literature. Office screening procedures will continue to play important roles in the diagnostic skills of the gynecologist.

Endoluminal gynecologic ultrasound: preliminary results.

Specially developed high-resolution real-time ultrasound transducers (12.5 and 20 MHz) on the tip of endoluminal catheters were inserted into the endometrial canal to evaluate the usefulness of this approach. Uterine abnormalities, most confirmed by biopsy, surgery, or both, were detected in 12 patients, including submucosal myomas, nabothian cysts, endometrial polyps, synechiae, and endometrial and cervical carcinoma. In one case the catheter was directed under hysteroscopic guidance into a fallopian tube, demonstrating its potential usefulness in this region. In 4 of the 12 cases in which a hysterectomy was performed, an in vitro ultrasound examination of the organ was performed, which confirmed the initial in vivo ultrasound impressions. Anatomic cross-sectional slices of the uterus resulted in excellent correlation with the ultrasound findings. These preliminary results suggest that this new sonographic procedure will become an important diagnostic tool, supplementing abdominal and endovaginal ultrasound approaches.

子宮筋腫に対する保存的治療としてのレーザー療法

YAG laser excision was performed for the treatment of sixty-three patients with uterine myoma (portio myoma; 1, endcervical myoma; 37, submucosal myoma of the corpus; 25).All patients except one (submucosal myoma) were treated at an outpatients basis. The local infiltration of 1% lidocaine was given to the cervix. The procedure was underwent with YAG laser attached to new ceramic rod (made of artificial sapphire) by using the contact method.The output power was delivered from 15 to 20 watts. All cases except 5 were cured successfully by having only one treatment. A case with endocervical myoma was operated on having transabdominal hysterectomy because of successive hypermenorrhea, but there was no lesion in the cavity. Four cases with endocervical myoma were reirradiated because of residual lesions. The side effects during and after the procedure were minimum. In conclusion, transvaginal laser therapy is the conservative one beneficial for the uterine myoma.