- Email: [email protected]
Isolated torsion of the fallopian tube in a patient with polycystic ovarian syndrome (PCOS)
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 215–221
218
tance, Holte et al. [4] determined a relation between elevated SBP and IR in both obese and lean patients. The excess in fat mass leads to an increase in free fatty acid levels and also increased secretion of inflammatory cytokines such as interleukin-6. IL-6 stimulates the central nervous system and the sympathetic nervous system, which may result in hypertension [5]. Therefore, the increase in SBP found in lean PCOS patients is probably related to insulin resistance and WHR. Our study revealed that HOMA index and testosterone are independent determinants of nondipper pattern in lean PCOS patients. The frequency of nondipper pattern was higher in women with PCOS when compared with lean controls. These data suggested that nondipper pattern is most probably related to insulin resistance and hyperandrogenemia in lean PCOS patients. Our data showed that lean women with PCOS presented a higher heart rate during nighttime when compared with the control group. This difference was found to be associated with increased free and total testosterone levels, WHR, and HOMA index. Serum testosterone level was previously identified as an independent predictor of sympathetic nerve activity to the muscle vascular bed in PCOS [5]. In this study also, elevated nighttime heart rate was found to be correlated with free and total testosterone, and fasting insulin levels. In conclusion, abnormalities in the regulation of blood pressure, including an increased ambulatory SBP, an increased nondipper pattern and an increased nighttime heart rate, are most common in lean PCOS patients. The study revealed that increased insulin resistance, WHR, as well as hyperandrogenemia may contribute to enhanced blood pressure variability in lean PCOS patients. Our study implies that practitioners should be aware of the risk of blood pressure abnormalities in lean PCOS patients with IR, increased WHR and hyperandrogenemia. References [1] Revised 2003 consensus on diagnostic criteria and long-term healthy risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19–25. [2] Belli SH, Graffigna MN, Oneta A, Otero P, Schurman L, Levalle OA. Effect of rosiglitazone on insulin resistance, growth factors, and reproductive disturbances in women with polycystic ovary syndrome. Fertil Steril 2004; 81:624–9. [3] Zimmermann S, Phillips RA, Dunaif A, et al. Polycystic ovary syndrome: lack of hypertension despite profound insulin resistance. J Clin Endocrinol Metab 1992;75:508–13. [4] Holte J, Gennarelli G, Berne C, Bergh C, Bergh T, Lithell H. Elevated ambulatory day-time blood pressure in women with polycystic ovary syndrome: a sign of a pre-hypertensive state? Hum Reprod 1996;11:23–8. [5] Fernandez-Real JM, Vayreda M, Rıchart C, et al. Circulating interleukin 6 levels, blood pressure, and insulin sensitivity in apparently healthy men and women. J Clin Endocrinol Metab 2001;1154–9.
Isolated torsion of the fallopian tube in a patient with polycystic ovarian syndrome (PCOS) Dear Editor, We present a case of chronic severe pelvic pain in a 31-year-old woman with known polycystic ovarian syndrome, later found to have isolated torsion of her left fallopian tube at laparoscopy. Following de-torsion, she became pain free. A 31-year-old primiparous woman was seen in the gynaecology outpatient department complaining of recurrent episodes of severe pelvic pain lasting hours to days. She had been diagnosed with polycystic ovarian syndrome in 2005 after investigations prompted by secondary amenorrhoea and delayed conception. She had previous emergency admissions for the same pain 7 years ago, but investigations were inconclusive and she was managed conservatively. On this occasion, an ultrasound scan performed prior to her clinic appointment showed a 16 mm 7 mm suspected hydrosalpinx and a small amount of free fluid. Preliminary investigations including haemoglobin and white cell count, mid-stream urine culture and genital swabs were all normal. In view of her recurrent symptoms, abnormal ultrasound finding and anxiety related to fertility, she was listed for a diagnostic laparoscopy with dye test. At laparoscopy, the right adnexa looked normal. Both ovaries looked bulky and polycystic. The left tube, however, was twisted on its distal part three times, although the tube itself appeared healthy (Fig. 1). Dye test was initially negative on the left side but following successful detorsion, free spill of dye was seen. The postoperative course was uneventful and the patient was discharged the next day. She was followed up 6 weeks later and reported her symptoms had completely resolved. Pre-operative pain scale was reported as 8–9 but this had reduced to 0. To the best of our knowledge this is the first reported case of isolated fallopian tube torsion in a patient with known polycystic ovarian syndrome (PCOS). Chronic pelvic pain is not a clinical feature commonly associated with PCOS and isolated torsion of the fallopian tube is a rare cause of acute and chronic lower abdominal pain with an incidence of 1 in 1,500,000 women [1]. It is difficult to argue an association between PCOS and isolated fallopian tube torsion from this single case and it would require a case series to test the hypothesis. However there has been a published case report of unilateral adenexal infarction associated with PCOS [2] which could have commenced with adenexal torsion although no direct evidence exists for this link. On a practical note, we feel it is
Cemil Kaya* Ufuk University, Department of Obstetrics and Gynecology, Mevlana Bulvar, No.: 82, 312 Ankara, Turkey Gogsen Onalan Bas¸kent University, Department of Obstetrics and Gynecology, Turkey S. Dinc¸er Cengiz Ankara University, Department of Obstetrics and Gynecology, Turkey *Corresponding author E-mail address: [email protected] (C. Kaya) 23 July 2008 doi:10.1016/j.ejogrb.2010.02.018
Fig. 1. Laparoscopic image of the pelvis showing torsion of the left fallopian tube.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 215–221
important that this case is brought to the attention of the wider clinical community so that when women with PCOS present with pelvic pain, adenexal torsion is considered along with other possible causes and prompt laparoscopy performed to salvage the fallopian tube and fertility, which is often an important consideration in these women. References [1] Nanda S, Walecha N, Singh RB. J Gynecol Surg 2006;22(4):157–62. [2] Olufowobi O, Sorinola O, Afnan M, Papaioannou S, McHugo JM, Sharif K. Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary. Obstet Gynecol 2002;100(5 Pt 2):1136–8.
Jasmine Tay* Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Imperial College NHS Trust, Praed Street, London W2 1NY, United Kingdom Helen Parker Pallavi Dhange Calum Paton-Forrester Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham NG7 2UH, United Kingdom William Atiomo School of Clinical Sciences, Division of Human Development, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom *Corresponding author at: Flat 12, 89 Gloucester Terrace, London W2 3HB, United Kingdom E-mail address: [email protected] (J. Tay) 21 November 2009 doi:10.1016/j.ejogrb.2010.02.043
Occurrence of endometrial cancer six years after treatment with thermal balloon ablation (Thermachoice1): first case report Dear Editor, We report a case of endometrial cancer occurring de novo six years after a Thermachoice1 procedure for dysfunctional uterine bleeding. To our knowledge, this is the first case described in the literature. A 48-year-old multiparous patient attended our outpatient clinic for uterine bleeding (menorrhagia and metrorrhagia). She had a past history of bilateral breast cancer treated with mastectomy and axillary lymph node dissection, and breast-conserving surgery without adjuvant hormone therapy. On physical examination, her height was 165 cm and weight 86 kg. She had no other risk factors for endometrial cancer. The uterine bleeding was diagnosed as functional after normal ultrasound examination of the endometrium and myometrium. A hysteroscopy (revealing a normal uterine cavity) was performed with biopsy-curettage. Pathological examination showed endometrium in the proliferative phase without atypia. She underwent Thermachoice1 therapy (controlled 83 8C intracavitary heating of the uterus for eight minutes using a
219
balloon technique) by an experienced surgeon. Metrorrhagia recurred six years later. A hydrosonography examination revealed an abnormal endometrial/uterine image (myoma and/or polyp) and an irregular thickening of the uterine fundus confirmed by hysteroscopy. Biopsy-curettage revealed atypical endometrial hyperplasia with a few clusters of grade 2 endometrioid endometrial adenocarcinoma cells. Treatment consisted of Piver type I hysterectomy with pelvic lymph node dissection. The final histological examination revealed a FIGO [1] stage IA, grade 2, endometrioid adenocarcinoma without lymph node involvement (right side: 0/7 and left side: 0/9) and with negative peritoneal cytology, associated with atypical endometrial epithelial hyperplasia lesions (no adenomyosis) mainly observed in the fundus. Endometrial ablation is an effective treatment for dysfunctional uterine bleeding [2], and thermal balloon endometrial ablation (Thermachoice1, a second-generation endometrial ablation device) is an alternative method used in the treatment of menorrhagia [3]. This minimally invasive non-hysteroscopic technique combines heat and pressure within the uterine cavity to destroy the endometrium and part of the myometrium [3]. Advantages of Thermachoice1 are less operating time and fewer complications compared with hysteroscopic methods [3]. The safety and effectiveness of this new technique were demonstrated but the number of patients or usual follow-up (12–24 months) in published studies were very low [3]. Although several case reports of endometrial cancer following endometrial ablation with rollerball and resectoscope have been published [4], few data are available after thermal balloon endometrial ablation. Lee et al. [5] reported a case of endometrial carcinoma to have occurred two months after the diagnosis of atypical hyperplasia in endometrium found in pipelle biopsy before Thermachoice1. The coexistence rate of endometrial cancer and atypical endometrial hyperplasia is between 15% and 50% in the literature [6]. Thus, the report of Lee et al. confirms the coexistence of endometrial cancer and atypical endometrial hyperplasia. In the present case, we can argue that the endometrial cancer occurred de novo after Thermachoice1 because: (a) the curettage six years earlier, before the Thermachoice1 procedure, was negative without atypical endometrial hyperplasia while the second biopsycurettage revealed atypical endometrial hyperplasia with endometrial adenocarcinoma cells; (b) the uterine cavity observed during the first hysteroscopy, done before the Thermachoice1 procedure, was regular and furthermore the endometrial cancer and atypical hyperplasia were located in the uterine fundus, which is particularly accessible to the Thermachoice1 system; and (c) the cancer is associated with atypical hyperplasia which is the step between normal endometrium and adenocarcinoma. Thus, complete endometrial thermoablation is not achieved with the Thermachoice1 system: a residual endometrial tissue where atypical endometrial hyperplasia and endometrial cancer can occur. Lee et al. [5] demonstrated that the Thermachoice1 procedure is not a treatment of endometrial cancer or atypical hyperplasia. With the present case report we demonstrate that Thermachoice1 should not be considered to prevent endometrial cancer or even atypical endometrial hyperplasia. Thermachoice1 is only a treatment for dysfunctional uterine bleeding. The present case report illustrates that recurrent uterine bleeding after Thermachoice1 requires a new exploration of the uterine cavity with hysteroscopy and biopsy-curettage. Conflict of interest Authors have no conflict of interest.
218
tance, Holte et al. [4] determined a relation between elevated SBP and IR in both obese and lean patients. The excess in fat mass leads to an increase in free fatty acid levels and also increased secretion of inflammatory cytokines such as interleukin-6. IL-6 stimulates the central nervous system and the sympathetic nervous system, which may result in hypertension [5]. Therefore, the increase in SBP found in lean PCOS patients is probably related to insulin resistance and WHR. Our study revealed that HOMA index and testosterone are independent determinants of nondipper pattern in lean PCOS patients. The frequency of nondipper pattern was higher in women with PCOS when compared with lean controls. These data suggested that nondipper pattern is most probably related to insulin resistance and hyperandrogenemia in lean PCOS patients. Our data showed that lean women with PCOS presented a higher heart rate during nighttime when compared with the control group. This difference was found to be associated with increased free and total testosterone levels, WHR, and HOMA index. Serum testosterone level was previously identified as an independent predictor of sympathetic nerve activity to the muscle vascular bed in PCOS [5]. In this study also, elevated nighttime heart rate was found to be correlated with free and total testosterone, and fasting insulin levels. In conclusion, abnormalities in the regulation of blood pressure, including an increased ambulatory SBP, an increased nondipper pattern and an increased nighttime heart rate, are most common in lean PCOS patients. The study revealed that increased insulin resistance, WHR, as well as hyperandrogenemia may contribute to enhanced blood pressure variability in lean PCOS patients. Our study implies that practitioners should be aware of the risk of blood pressure abnormalities in lean PCOS patients with IR, increased WHR and hyperandrogenemia. References [1] Revised 2003 consensus on diagnostic criteria and long-term healthy risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19–25. [2] Belli SH, Graffigna MN, Oneta A, Otero P, Schurman L, Levalle OA. Effect of rosiglitazone on insulin resistance, growth factors, and reproductive disturbances in women with polycystic ovary syndrome. Fertil Steril 2004; 81:624–9. [3] Zimmermann S, Phillips RA, Dunaif A, et al. Polycystic ovary syndrome: lack of hypertension despite profound insulin resistance. J Clin Endocrinol Metab 1992;75:508–13. [4] Holte J, Gennarelli G, Berne C, Bergh C, Bergh T, Lithell H. Elevated ambulatory day-time blood pressure in women with polycystic ovary syndrome: a sign of a pre-hypertensive state? Hum Reprod 1996;11:23–8. [5] Fernandez-Real JM, Vayreda M, Rıchart C, et al. Circulating interleukin 6 levels, blood pressure, and insulin sensitivity in apparently healthy men and women. J Clin Endocrinol Metab 2001;1154–9.
Isolated torsion of the fallopian tube in a patient with polycystic ovarian syndrome (PCOS) Dear Editor, We present a case of chronic severe pelvic pain in a 31-year-old woman with known polycystic ovarian syndrome, later found to have isolated torsion of her left fallopian tube at laparoscopy. Following de-torsion, she became pain free. A 31-year-old primiparous woman was seen in the gynaecology outpatient department complaining of recurrent episodes of severe pelvic pain lasting hours to days. She had been diagnosed with polycystic ovarian syndrome in 2005 after investigations prompted by secondary amenorrhoea and delayed conception. She had previous emergency admissions for the same pain 7 years ago, but investigations were inconclusive and she was managed conservatively. On this occasion, an ultrasound scan performed prior to her clinic appointment showed a 16 mm 7 mm suspected hydrosalpinx and a small amount of free fluid. Preliminary investigations including haemoglobin and white cell count, mid-stream urine culture and genital swabs were all normal. In view of her recurrent symptoms, abnormal ultrasound finding and anxiety related to fertility, she was listed for a diagnostic laparoscopy with dye test. At laparoscopy, the right adnexa looked normal. Both ovaries looked bulky and polycystic. The left tube, however, was twisted on its distal part three times, although the tube itself appeared healthy (Fig. 1). Dye test was initially negative on the left side but following successful detorsion, free spill of dye was seen. The postoperative course was uneventful and the patient was discharged the next day. She was followed up 6 weeks later and reported her symptoms had completely resolved. Pre-operative pain scale was reported as 8–9 but this had reduced to 0. To the best of our knowledge this is the first reported case of isolated fallopian tube torsion in a patient with known polycystic ovarian syndrome (PCOS). Chronic pelvic pain is not a clinical feature commonly associated with PCOS and isolated torsion of the fallopian tube is a rare cause of acute and chronic lower abdominal pain with an incidence of 1 in 1,500,000 women [1]. It is difficult to argue an association between PCOS and isolated fallopian tube torsion from this single case and it would require a case series to test the hypothesis. However there has been a published case report of unilateral adenexal infarction associated with PCOS [2] which could have commenced with adenexal torsion although no direct evidence exists for this link. On a practical note, we feel it is
Cemil Kaya* Ufuk University, Department of Obstetrics and Gynecology, Mevlana Bulvar, No.: 82, 312 Ankara, Turkey Gogsen Onalan Bas¸kent University, Department of Obstetrics and Gynecology, Turkey S. Dinc¸er Cengiz Ankara University, Department of Obstetrics and Gynecology, Turkey *Corresponding author E-mail address: [email protected] (C. Kaya) 23 July 2008 doi:10.1016/j.ejogrb.2010.02.018
Fig. 1. Laparoscopic image of the pelvis showing torsion of the left fallopian tube.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 150 (2010) 215–221
important that this case is brought to the attention of the wider clinical community so that when women with PCOS present with pelvic pain, adenexal torsion is considered along with other possible causes and prompt laparoscopy performed to salvage the fallopian tube and fertility, which is often an important consideration in these women. References [1] Nanda S, Walecha N, Singh RB. J Gynecol Surg 2006;22(4):157–62. [2] Olufowobi O, Sorinola O, Afnan M, Papaioannou S, McHugo JM, Sharif K. Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary. Obstet Gynecol 2002;100(5 Pt 2):1136–8.
Jasmine Tay* Department of Obstetrics and Gynaecology, St. Mary’s Hospital, Imperial College NHS Trust, Praed Street, London W2 1NY, United Kingdom Helen Parker Pallavi Dhange Calum Paton-Forrester Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham NG7 2UH, United Kingdom William Atiomo School of Clinical Sciences, Division of Human Development, University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom *Corresponding author at: Flat 12, 89 Gloucester Terrace, London W2 3HB, United Kingdom E-mail address: [email protected] (J. Tay) 21 November 2009 doi:10.1016/j.ejogrb.2010.02.043
Occurrence of endometrial cancer six years after treatment with thermal balloon ablation (Thermachoice1): first case report Dear Editor, We report a case of endometrial cancer occurring de novo six years after a Thermachoice1 procedure for dysfunctional uterine bleeding. To our knowledge, this is the first case described in the literature. A 48-year-old multiparous patient attended our outpatient clinic for uterine bleeding (menorrhagia and metrorrhagia). She had a past history of bilateral breast cancer treated with mastectomy and axillary lymph node dissection, and breast-conserving surgery without adjuvant hormone therapy. On physical examination, her height was 165 cm and weight 86 kg. She had no other risk factors for endometrial cancer. The uterine bleeding was diagnosed as functional after normal ultrasound examination of the endometrium and myometrium. A hysteroscopy (revealing a normal uterine cavity) was performed with biopsy-curettage. Pathological examination showed endometrium in the proliferative phase without atypia. She underwent Thermachoice1 therapy (controlled 83 8C intracavitary heating of the uterus for eight minutes using a
219
balloon technique) by an experienced surgeon. Metrorrhagia recurred six years later. A hydrosonography examination revealed an abnormal endometrial/uterine image (myoma and/or polyp) and an irregular thickening of the uterine fundus confirmed by hysteroscopy. Biopsy-curettage revealed atypical endometrial hyperplasia with a few clusters of grade 2 endometrioid endometrial adenocarcinoma cells. Treatment consisted of Piver type I hysterectomy with pelvic lymph node dissection. The final histological examination revealed a FIGO [1] stage IA, grade 2, endometrioid adenocarcinoma without lymph node involvement (right side: 0/7 and left side: 0/9) and with negative peritoneal cytology, associated with atypical endometrial epithelial hyperplasia lesions (no adenomyosis) mainly observed in the fundus. Endometrial ablation is an effective treatment for dysfunctional uterine bleeding [2], and thermal balloon endometrial ablation (Thermachoice1, a second-generation endometrial ablation device) is an alternative method used in the treatment of menorrhagia [3]. This minimally invasive non-hysteroscopic technique combines heat and pressure within the uterine cavity to destroy the endometrium and part of the myometrium [3]. Advantages of Thermachoice1 are less operating time and fewer complications compared with hysteroscopic methods [3]. The safety and effectiveness of this new technique were demonstrated but the number of patients or usual follow-up (12–24 months) in published studies were very low [3]. Although several case reports of endometrial cancer following endometrial ablation with rollerball and resectoscope have been published [4], few data are available after thermal balloon endometrial ablation. Lee et al. [5] reported a case of endometrial carcinoma to have occurred two months after the diagnosis of atypical hyperplasia in endometrium found in pipelle biopsy before Thermachoice1. The coexistence rate of endometrial cancer and atypical endometrial hyperplasia is between 15% and 50% in the literature [6]. Thus, the report of Lee et al. confirms the coexistence of endometrial cancer and atypical endometrial hyperplasia. In the present case, we can argue that the endometrial cancer occurred de novo after Thermachoice1 because: (a) the curettage six years earlier, before the Thermachoice1 procedure, was negative without atypical endometrial hyperplasia while the second biopsycurettage revealed atypical endometrial hyperplasia with endometrial adenocarcinoma cells; (b) the uterine cavity observed during the first hysteroscopy, done before the Thermachoice1 procedure, was regular and furthermore the endometrial cancer and atypical hyperplasia were located in the uterine fundus, which is particularly accessible to the Thermachoice1 system; and (c) the cancer is associated with atypical hyperplasia which is the step between normal endometrium and adenocarcinoma. Thus, complete endometrial thermoablation is not achieved with the Thermachoice1 system: a residual endometrial tissue where atypical endometrial hyperplasia and endometrial cancer can occur. Lee et al. [5] demonstrated that the Thermachoice1 procedure is not a treatment of endometrial cancer or atypical hyperplasia. With the present case report we demonstrate that Thermachoice1 should not be considered to prevent endometrial cancer or even atypical endometrial hyperplasia. Thermachoice1 is only a treatment for dysfunctional uterine bleeding. The present case report illustrates that recurrent uterine bleeding after Thermachoice1 requires a new exploration of the uterine cavity with hysteroscopy and biopsy-curettage. Conflict of interest Authors have no conflict of interest.