1/63. OB/GYN virtual consult--menorrhagia for 6 months in a 31-year-old. What treatment options would you advise for a young woman with vaginal bleeding of 6 months' duration? Malcolm Griffiths, MD, in the Department of obstetrics and Gynaecology, Luton & Dunstable Hospital, Luton, UK, moderates this case. ( info) |
| Although progestational agents have been widely used for gynecologic conditions, treatment options have usually been limited to synthetic agents with adverse effects and sparse patient acceptance. Recent food and Drug Administration approval of oral micronized progesterone (MP) has introduced therapy with a safe, effective, well-tolerated drug. This article reviews therapeutic indications for MP as illustrated in five case studies. Issues of patient compliance, individualized treatment plans, and patient partnership to obtain the most beneficial outcomes are discussed. ( info) |
3/63. Fine-needle aspiration cytology of primary granulosa cell tumor of the adrenal gland: a case report. Extraovarian granulosa cell tumors are extremely rare. We report on a primary granulosa cell tumor of the adrenal gland. A 69-yr-old African-American female presented with a 1-yr history of irregular uterine bleeding and a palpable right abdominal mass. CT scan showed a 9.0-cm suprarenal mass as well as an enlarged uterus. CT-guided fine-needle aspiration (FNA) cytology of the adrenal mass was interpreted as a malignant neoplasm. She underwent exploratory laparotomy, right nephrectomy, and hysterectomy with bilateral salpingo-oophorectomy. The gross, histologic, and immunohistochemical findings of the adrenal mass were characteristic of a granulosa cell tumor. The uterus contained multiple leiomyomas. The endometrium showed simple hyperplasia. Both fallopian tubes and ovaries showed no pathologic abnormality. There was no evidence of tumor elsewhere. Although rare, extraovarian granulosa cell tumor should be considered in the differential diagnosis of adrenal tumors in women showing the FNA features described herein, especially when there is evidence of excessive estrogen production. Diagn. Cytopathol. 2000;22:107-109. ( info) |
4/63. Mucinous endometrial adenocarcinoma simulating microglandular hyperplasia of the cervix. A case of endometrial adenocarcinoma simulating microglandular hyperplasia (MGH) of the cervix is presented. A postmenopausal 53-year-old woman, with no previous history of taking exogenous hormones, presented with vaginal bleeding. An endometrial biopsy exhibited a tumor composed predominantly of a microglandular proliferation of tightly packed glands with mild to moderate atypia and mitotic figures. The majority of the tumor cells contained intracytoplasmic mucin. There were numerous neutrophils within the microglandular lumens and in the stroma. The tumor was focally positive for carcinoembryonic antigen and vimentin. The MGH-like proliferation, focally, had a transition to a conventional mucinous adenocarcinoma. hysterectomy specimens showed a residual mucinous endometrial adenocarcinoma with no myometrial invasion, the uterine cervix was unremarkable. Four years following her hysterectomy the patient was well, with no evidence of disease. Pathologists need to be cautious about MGH-like changes in the endometrial biopsy of postmenopausal women and be aware of this type of endometrial cancer as it may be misdiagnosed. ( info) |
| mifepristone (RU486) is a potent antiprogestagen, and at high doses it also acts as an antiglucocorticoid drug. mifepristone, administered as a single 600 mg dose, is commonly employed to induce medical abortion in conjunction with prostaglandins. The long-term safety profile of mifepristone, especially at high doses, is less well-established. Long-term mifepristone is considered efficacious in treating uterine myomas, endometriosis (25--100 mg/day), and possibly in inoperable meningiomas (200 mg/day), as well as inoperable Cushing's syndrome. Many animal studies document an antiproliferative effect (antioestrogenic), as do some reports in humans. However, there are also data to suggest that, as an antiprogestagen, mifepristone may promote an unopposed oestrogen milieu, and thus have a proliferative effect upon the endometrium. We hereby describe the first reported case of an adolescent female with Cushingoid features and morbid osteoporosis who was treated with mifepristone for its antiglucocorticoid effect (400 mg/day) in an attempt to prevent further bone loss. The patient's striae, weight gain, and buffalo hump markedly improved, and further bone loss was halted. However, with each of the two 6-month courses of mifepristone (9 months apart) she developed massive simple endometrial hyperplasia and a markedly enlarged uterus. This reversed to normal after cessation of mifepristone treatment. In conclusion, High doses of the antiprogestagen mifepristone over a prolonged period of time may promote an unopposed oestrogen milieu leading to endometrial hyperplasia. Therefore, interval pelvic imaging in women who receive long-term mifepristone may be prudent. ( info) |
| BACKGROUND: Successful pregnancy in a woman with complex endometrial hyperplasia with atypia was treated conservatively with gestagens. CASE: The patient was initially diagnosed with complex hyperplasia of the endometrium with atypia by endometrial curettage and treated with several cycles of different gestagens. After repeated endometrial curettage, in vitro fertilization and embryo transfer were introduced for immediate treatment of the patient's infertility in order to avoid the risk of recurrent hyperplasia of the endometrium from estrogens. A single pregnancy was achieved after transfer of embryos obtained from intracytoplasmic sperm injection. This was performed due to poor semen characteristics. The patient delivered a normal, healthy male infant at term. CONCLUSION: Conservative treatment of complex endometrial hyperplasia with atypia in young women wishing to preserve fertility should be considered in carefully selected cases. ( info) |
7/63. Balloon thermoablation in a woman with complex endometrial hyperplasia with atypia. A case report. BACKGROUND: Endometrial ablation is an alternative to hysterectomy in patients with menorrhagia refractory to medical therapy. The histologic changes in the hyperplastic endometrium secondary to endometrial ablation are not well understood. CASE REPORT: A 44-year-old woman, gravida 4, para 4, had menorrhagia, was at high risk for medical treatment and underwent thermal balloon ablation. The dilatation and curettage specimen at the time of the procedure revealed complex hyperplasia of the endometrium with atypia. Subsequently a hysterectomy was performed, and the pathology specimen showed scarring, fibrosis and focal, weakly proliferative phase endometrium. There was no evidence of hyperplasia or malignancy. CONCLUSION: Endometrial ablation with a thermal balloon seems to have resulted in resolution of endometrial hyperplasia. However, hyperplasia of the endometrium should still be a contraindication to such a procedure because of the inability to accurately assess the endometrium after ablation. ( info) |
8/63. Spontaneous rupture of the spleen following abdominal hysterectomy. Summary: The authors described a rare case of spontaneous splenic rupture following abdominal hysterectomy in a patient with adenomyosis, severe sideropenic anemia and initiated anticoagulant therapy with low molecular heparin. ( info) |
9/63. Atypical complex endometrial hyperplasia treated with the GyneLase system. A 47-year-old premenopausal, para 1, gravida 1 woman complained of menometrorrhagia. She had no risk factors for endometrial hyperplasia or cancer, and office endometrial biopsy indicated focal, nonatypical endometrial hyperplasia. Seven months later the patient was scheduled for hysteroscopic endometrial resection. Instead she was treated by hysteroscopy, curettage, and the GyneLase system. The curetting indicated atypical, complex endometrial hyperplasia. The woman refused hysterectomy and salpingo-oophorectomy and adjunctive therapy with progesterone. She agreed to close surveillance and further treatment if she had any vaginal bleeding. At 13 months she remains amenorrheic, the endometrial echo is 2 mm, and follicle-stimulating hormone level is 63 IU/L. Based on the patient's amenorrhea and ultrasound uterine measurement, it is tempting to assume that GyneLase treatment may have cured her atypical hyperplasia. However, at this time, we have no evidence to substantiate this assumption. ( info) |
10/63. Nodular histiocytic hyperplasia of the endometrium. We describe the clinical and pathologic features of four cases of nodular histiocytic proliferation in the endometrium. We have been able to find only one brief reference to this lesion in the literature. The lesion in each case was a detached nodule composed of aggregates of histiocytes within a biopsy or curettage specimen. The constituent cells differed from foamy histiocytes of the endometrium in that they had either lobulated or ovoid, vesicular nuclei, distinctive cytoplasmic margins, and a moderate amount of amphophilic cytoplasm. Mitoses were frequent (up to 11 per 10 high-power fields) in one case but were absent in the remaining cases. On immunohistochemical staining, CD68 and lysozyme were strongly expressed in the cytoplasm. Neither estrogen receptor nor progesterone receptor was expressed in contrast to the background endometrium. The cells were also negative for S-100 and cytokeratin. Each patient's postcurettage course was uneventful. The cause of nodular histiocytic proliferation of the endometrium is currently unknown, although response to intracavitary debris has been suggested. The lesion should not be confused with a variety of reactive, inflammatory, or neoplastic conditions, such as xanthogranulomatous endometritis, malakoplakia, histiocytic granuloma, hormonal changes of the endometrial stroma, Langerhans' cell histiocytosis, morular metaplasia, extravillous trophoblast, or exaggerated placental site reaction. ( info) |