Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms

PURPOSE

The objective of this study was to evaluate the efficacy of fractional CO₂ laser to manage vulvar and vaginal symptoms of Genitourinary Syndrome of Menopause (GSM) in postmenopausal women.

METHODS

All postmenopausal women with symptoms of GSM undergoing fractional CO₂ laser treatment in our centers were asked to fill out a validated quality of life questionnaire (Global Quality of Life Questionnaire), Visual Analog Scale (VAS) for symptoms, a questionnaire on overall discomfort related to pelvic floor symptoms, and the Female Sexual Function Index (FSFI) at several points: before each session (three sessions at monthly intervals) and one 3 months after treatment completion. Statistical analysis compared pre-therapy data and data at 3 months of treatment.

RESULTS

Forty-six women were included with a mean age of 57.3 years (± 11.1 years). A significant improvement was demonstrated in vaginal dryness (p = 6.34 10^-6) and for symptoms of stress urinary incontinence (p = 0.043). Among sexually active patients, there was a significant improvement in the degree of symptom discomfort affecting their satisfaction (p = 0.007), dyspareunia (p = 0.001) and sensitivity during sexual intercourse (p = 0.001). Significantly, more women were able to achieve (p = 0.026) and maintain (p = 0.018) lubrication during intercourse.

CONCLUSION

CO₂ laser treatment seems to improve the quality of life and sexual health of patients as well as GSM symptoms at 3 months of treatment; long-term reevaluation is necessary to demonstrate that improvement persists over time.

[Menorrhagia after age 40. Contribution of ultrasonic examination]

Menorrhagia after age 40 can have functional, general, local, or organic reasons. The most frequent are: submucous myomas, adenomyosis, polyps. Submucous myomas: a transvaginal scan (TVUS) specifies the type of myoma according to its situation within the uterine cavity: intracavitary myoma or submucous. A transvaginal scan is performed to assess myomas before operative HSC. There are three criteria to check: myomas diameter must be less than 5 cm; 5 mm or more of normal myometrium should be present between myoma and external wall; the myoma must not be in contiguity with a subserosal myoma. Uterine adenomyosis is a common gynecologic condition that is characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. Pathology may be proximal or distal, focal or diffuse. Transvaginal US shows: cystic dilatation of heterotopic glands, heterogeneity of the myometrial echotexture, antero-posterior asymmetry of the uterus. TVUS has a sensitivity of 62 to 89% and a specificity of 89 to 96%. Polyps are most often hyperechoic: this makes the diagnosis more difficult in luteal phase; Power Doppler shows the vascular central pedicle. TVUS has a sensitivity of 75%. The polyps smaller than 3 mm are not visible in a reliable way without the help of a contrast media in the cavity.

Loss of heterozygosity on the short arm of chromosome 3 in cervical intra-epithelial neoplasia without concomitant cervical carcinoma

Losses of heterozygosity on the short arm of chromosome 3p are common in cervical carcinomas in the 3p13-3p21 region, and can be observed in intra-epithelial lesions accompanying cervical cancers. As a preliminary attempt to determine whether these losses can be observed in intra-epithelial cervical lesions without concomitant invasive carcinoma, we have used two microsatellite markers located at the two most frequently deleted segments of the 3p13-3p21 region. We have studied 36 cases of grade II and grade III cervical intra-epithelial neoplasias obtained by conisation biopsies and 30 cases of cervical carcinoma including 3 micro-invasive squamous cell carcinomas. We found loss of heterozygosity or microsatellite instability in 6 of 16 (38%) and 9 of 23 (39%) informative cases of cervical carcinoma at 3p13 and 3p21, respectively. Four of 27 (15%) cases of cervical intra-epithelial neoplasia showed loss of heterozygosity at 3p13, whereas loss of heterozygosity or microsatellite instability at 3p21 was found in 5 of 19 cases (26%). No relationship was found between 3p loss of heterozygosity and human papillomavirus infection. In conclusion, losses of heterozygosity at 3p13 and 3p21 occur in premalignant lesions without concomitant invasive lesions. The prevalence and precise extent of these losses should be established by a more extensive analysis.

[Role of hysteroscopy in the diagnosis and treatment of infertility]

UTERINE DISORDERS: Because they can prevent implantation, anomalies within the uterine cavity play an important role in fertility. The uterine disorders most often observed during hysteroscopy and implicated in infertility are adhesions, septa, polyps, submucous myomas, adenomyosis, endometritis, anomalies of the cervical canal, and lesions of the uterotubal junction.

EXPLORATIONS

Hysterosalpingography can be used to evaluate tubal permeability but provides inadequate information about the uterine cavity (numerous false-positives and false-negatives). Pelvic ultrasound is especially helpful for diagnosing interstitial anomalies in the uterus.

HYSTEROSCOPY

Diagnostic hysteroscopy also has a place in infertility investigations, for it allows direct visualization of the uterine cavity, the endometrial mucus (endometritis, adenomyosis), and the cervical canal. The examination is practiced on a out-patient basis, without anesthesia, using appropriate small-caliber instruments and irrigation with physiological saline. Surgical hysteroscopy is used to treat these anomalies. Patients receive general anesthesia. A high-frequency, low-voltage electric current is used, and glycine for irrigation. This procedure allows resection of submucous myomas and polyps and of septa and adhesions. Some groups use laser beams and irrigation by physiological saline for these treatments. Coagulation of a superficial focal spot of adenomyosis is not useful in infertility therapy.

RESULTS

As assessed by the percentage of patients with each indication who subsequently became pregnant, the results of surgical hysteroscopy have been satisfactory: 62 per cent (%) of cases after myomectomy, 66% after section of uterine septa, and 61% after treatment of complicated adhesions. A new exploration of the uterine cavity will be necessary sometime after the surgery to verify the absence of any iatrogenic disorders (adhesions, myomatous fragments).

[The infected cervix]

Cervico-vaginal infections while easily identified, can in certain cases, in fact quite frequently, be under-diagnosed because of the absence of visible symptoms. Colposcopic access to the cervix or vagina can aid diagnosis of cervico-vaginal infections but may not be adequate to pinpoint the agent of the infection except in certain cases such as Herpes and HPV. On the other hand, cervical-vaginal infections can impede a colposcopic interpretation such as identifying the squamo-columnar junction or the location of a directed biopsy. Cervical infections can equally cause unexpected complications (notably Haemorrhagie or pelvic infections) during or after surgical Colposcopic procedures.

[Sonohysterography: a new study method of the uterine cavity: evaluation of 84 cases and comparison to hysteroscopy]

Sonohysterography versus hysteroscopy: the assessment of the uterine cavity: a series of 84 cases. We study indications, advantages, limits of a technic of investigation of uterine cavity: sonohysterography. Our results show that sonohysterography is as effective as hysteroscopy in the diagnosis of intrauterine conditions. It is painless, no time consuming. There is no adverse effects and it is helpful in the diagnosis of intrauterine abnormality as a complement of transvaginal scanning.

[Electro-conization with the diathermic loop. Indications and results]

The experiment of electro-conization with diathermic loop was effected on 185 patients. The indications are represented by: a) low grade lesions: 21 cases (11.3%) only when the squamo-columnar junction was into the endocervix; b) CIN 2: 44 cases (23.7%): c) CIN 3: 118 cases (63.7%); d) cyto-histologic discordance: 2 cases. After one year, the following results could be noted: 94.1% of the patients were cured, only 11 out of the 185 presented a recurrence (or persistence). It seemed interesting to us to study the factors which could influence the "in sano" (Free margin)/or not character of the resection. It appeared that the surface of the lesion did not seem to influence its histological result since we got: 83%, 96%, 94.5% and 92.3% of "in sano" conizations to be correlated with a lesion surface equal to 1/4, 2/4, 3/4, 4/4 of the cervical area. The second factor to be studied was the patients' age. So from 15 to 25 years (96%) of the resections were "in sano". There from 26 to 35 (92%), and from 36 to 45 (91.9%). Among post-menopausal women from 46 to 55 years old only 86.4% of electro-conizations were "in sano". Histologic alterations of the histologic specimen were noted in two cases (1%), the interpretation was easy and clear in the other cases. What about the complications? In 2 cases a moderate stenosis was to be noted; in 2 other cases: post-operative hemorragiae which were treated by a selective electro-coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hysteroscopic resection of the uterine septum]

An endoscopic alternative to the surgical treatment of uterine septum is presented. The hysteroscopic technique of septal division is described on the basis of 7 preliminary cases, with emphasis on the equipment used, the choice of the irrigation system, the problems encountered near the fundus uteri, where it is important to spare the myometrium, and the adjuvant treatments, notably in the post-operative period. Interventional hysteroscopy has a very low trans--and post-operative morbidity and seems to be a suitable procedure for the treatment of this type of uterine malformation.

Cervical surgery in infertility

We wish to stress three original techniques among the numerous operations which can be performed on the uterine cervix for the treatment of infertility. The first treatment is for cervical dysplasia of the cervix, a conization performed by electrosurgery under local anaesthesia, using a metallic handle of 23 mm, associated with vaporization by a CO2 laser at the edges of the resection. This technique, used for 125 patients, has permitted adequate resection. The rate of incomplete resection is less than 10%. This method has preserved the possibility of pregnancies without abortion. The second technique is the surgical repair of a large post-obstetrical split of the cervix by an abdominal exposure. After dissection of the bladder, the vagina is opened longitudinally, the cervix exposed and repaired carefully. Four patients who had previously had four to six abortions between 4 and 6 months of gestation, succeeded in achieving a full-term pregnancy by this technique. The third technique is the resection of the isthmic septum by microscissors or micro-electrocautery under local or general anaesthesia by hysteroscopy. Twelve cases, five with primary infertility, seven with second infertility and habitual abortions, were operated on by this technique in 1986-87. Four pregnancies have resulted.

[Condylomatous lesions: stages of cervical carcinogenesis]

Cervical condylomatous lesions are associated with a sexually transmissible virus: the Human papilloma virus. The authors discuss its highly probable carcinogenic role and they analyse its epidemiological profile, histoclinical data and the results of virological research.

[Occurrence and course of condylomata of the cervix during pregnancy]

This study analyses the frequency and the way cervical condylomata develop during pregnancy. We looked at 102 case notes of patients with condylomata in pregnancy which were diagnosed between September 1979 and September 1982. The incidence of pregnancy in patients with these condylomatous conditions is 1.3% and the incidence of these condylomatous conditions in pregnant women is 2.12%, which is three times that found in the general population. The authors analyse the distribution of straightforward condylomata and atypical ones and the way they evolve in pregnancy. Pure condylomata regress in 83% of cases. There has never been a case of invasion during the observation we have carried Out on carcinomata in situ. The distribution between pure condylomata (50%) and condylomata associated with various degrees of dysplasia (50%) has been studied and compared with that in the general population.