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Patients with very high risk of cancer mutation may decide to undergo prophylactic surgery in order to avoid heavy clinical and radiological monitoring. This is a promising and nonetheless risky surgery because it is a complicated procedure and highly mutilating. Our goal was to improve the practice of this prophylactic surgery, to do so we assessed a postoperative satisfaction survey to cancer-free patients who have undergone this procedure.Single-center, cross-sectional descriptive study. Assessment of the primary efficacy endpoint using the BREAST-Q questionnaire. These results were compared to a control group representative of our sample of patients, those data came from the scientific literature using a single-sample Student's test. Several multivariate analyzes were also carried out in order to study the influence of certain factors on the patient's satisfaction.The averages obtained in the various questionnaires were 56.06/100 for "Satisfaction with breasts"; 66.94/100 for "Psychosocial well-being"; 50/100 for "Sexual well-being" and 59.22/100 for "Satisfaction with information". Postoperative satisfaction in our sample is comparable to the group control concerning the questionnaire "Satisfaction with breasts" (P=0.37) and "Psychosocial well-being" (P=0.18). Concerning the questionnaire "Sexual well-being" there is a significant statistical difference between our group and the control group (P=0.01).The post-operative satisfaction of our operated patients seems to be proportionally similar to the general population who have not undergone breast surgery except on the question of the quality of sexual life. The various analyzes of our study also allowed us to highlight the importance of preoperative information for postoperative well-being.

This work was carried out under the aegis of the CNGOF (Collège national des gynécologues et obstétriciens français) and proposes guidelines based on the evidence available in the literature. The objective was to define the diagnostic and surgical management strategy, the fertility preservation and surveillance strategy in Borderline Ovarian Tumor (BOT). No screening modality can be proposed in the general population. An expert pathological review is recommended in case of doubt concerning the borderline nature, the histological subtype, the invasive nature of the implant, for all micropapillary/cribriform serous BOT or in the presence of peritoneal implants, and for all mucinous or clear cell tumors (grade C). Macroscopic MRI analysis should be performed to differentiate the different subtypes of BOT: serous, seromucinous and mucinous (intestinal type) (grade C). If preoperative biomarkers are normal, follow up of biomarkers is not recommended (grade C). In cases of bilateral early serous BOT with a desire to preserve fertility and/or endocrine function, it is recommended to perform a bilateral cystectomy if possible (grade B). In case of early mucinous BOT, with a desire to preserve fertility and/or endocrine function, it is recommended to perform a unilateral adnexectomy (grade C). Secondary surgical staging is recommended in case of serous BOT with micropapillary appearance and uncomplete inspection of the abdominal cavity during initial surgery (grade C). For early-stage serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (grade C). Follow up after BOT must be pursued for more than 5 years (grade B). Conservative treatment involving at least the conservation of the uterus and a fragment of the ovary in a patient wishing to conceive may be proposed in advanced stages of BOT (grade C). A new surgical treatment that preserves fertility after a first non-invasive recurrence may be proposed in women of childbearing age (grade C). It is recommended to offer a specialized consultation for Reproductive Medicine when diagnosing BOT in a woman of childbearing age. Hormonal contraceptive use after serous or mucinous BOT is not contraindicated (grade C).

To determine the procedures for follow-up and counselling of patients after pelvic inflammatory disease (PID).A search in the Cochrane database, PubMed, and Google was performed using keywords related to follow-up and PID to identify reports published between 1990 and 2018. All studies published in French and English relevant to the areas of focus were included. A level of evidence (LE) based on the quality of the data available was applied for each area of focus and used for the guidelines.The rate of recurrent PID is 15 to 21%. They are related to a recurrent sexually transmitted infection (STI) in 20 to 34% of cases. Recurrence PID increase the risk of infertility and chronic pelvic pain (LE2). Follow-up is recommended after PID (grade C). The rate of patients lost to follow-up is around 40%. Follow-up is improved by personalized text message reminders (grade B). Vaginal sampling for detection of N. gonorrhoeae, C. trachomatis, (and M. genitalium) by nucleic acid amplification techniques is recommended 3 to 6 months after treatment of PID associated with STI to rule out possible reinfections (grade C). The use of condoms after PID associated with STI is recommended to reduce the risk of recurrences (grade C). The systematic use of contraceptive pills after PID is not recommended to prevent subsequent infertility and chronic pelvic pain. Vaginal sampling for microbiological diagnosis is recommended before the insertion of an intrauterine device (grade B). The risk of ectopic pregnancy is high in these women and must be kept in mind.Patient counselling and microbiological testing after PID decrease the risk of STI and thus the recurrence of PID.

To provide up-to-date guidelines on management of pelvic inflammatory disease (PID).An initial search of the Cochrane database, PubMed, and Embase was performed using keywords related to PID to identify reports in any language published between January 1990 and January 2012, with an update in 2018. All identified reports published in French and English relevant to the areas of focus were included. A level of evidence based on the quality of the data available was applied for each area of focus and used for the guidelines.PID must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade B). Pelvic ultrasonography is necessary to exclude tubo-ovarian abscess (TOA) (grade C). Microbiological diagnosis requires endocervical and TOA sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ceftriaxone 1g, once, by intra-muscular (IM) or intra-venous (IV) route, doxycycline 100mg×2/d, and metronidazole 500mg×2/d oral (PO) for 10 days (grade A). First-line treatment for complicated PID combines IV ceftriaxone 1 to 2g/d until clinical improvement, doxycycline 100mg×2/d, IV or PO, and metronidazole 500mg×3/d, IV or PO for 14days (grade B). Drainage of TOA is indicated if the collection measures more than 3cm (grade B). Follow-up is required in women with sexually transmitted infections (STI) (grade C). The use of condoms is recommended (grade B). Vaginal sampling for microbiological diagnosis is recommended 3 to 6months after PID (grade C), before the insertion of an intra-uterine device (grade B), before elective termination of pregnancy or hysterosalpingography. Targeted antibiotics on identified bacteria are better than systematic antibioprophylaxis in those conditions.Current management of PID requires easily reproducible investigations and antibiotics adapted to STI and vaginal microbiota.

The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France.The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017.Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation.Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.

La tuberculose genitale est rare. L’absence de specificite clinique fait la difficulte d’evoquer cette infection et le diagnostic est souvent tardif. Nous rapportons deux cas observes chez des femmes jeunes, de 22 et de 33 ans, consultant pour infertilite primaire et amenorrhee. Le diagnostic a ete porte par l’examen anatomopathologique d’une biopsie de peritoine et d’epiploon pour le premier cas et le produit de curetage biopsique de l’endometre pour la deuxieme patiente. Les deux examens revelaient des granulomes gigantocellulaires et des necroses caseeuses, qui sont des lesions pathognomoniques de la tuberculose. La tuberculose doit etre evoquee et recherchee chez toute femme presentant une amenorrhee secondaire, mais surtout il faut penser a l’inclure dans le bilan d’infertilite particulierement dans les pays ou la tuberculose est encore endemique comme Madagascar.

Objectives To analyse the management of pregnancy after prenatal diagnosis of sex chromosome aneuploidy (SCA) and the factors influencing genetic counselling and parental decision. Methods Between 1991 and 2001, 73 non-mosaic fetal SCA were diagnosed in our centre and 25 were referred to us from outside institutions. The same geneticist carried out genetic counselling. The outcome of pregnancies and the termination trend over time were determined according to the type of SCA. Clinical parental data were analysed in order to assess whether they influenced genetic counselling. Results 45,X was diagnosed in 41 fetuses. The main indication for karyotyping was abnormal ultrasound (83%). The termination rate was 93%. Sex chromosome polysomies (SCP) including 47,XXY, 47,XXX, and 47,XYY were diagnosed in 31, 16, and 10 fetuses respectively. The main indication for karyotyping was advanced maternal age (60%). The termination rate was 32, 25, and 20% respectively. The difference between the termination rate for local cases (25%) and referred cases (33%) was not significant. The termination rate for pregnancies with SCP was 38% in 1991 to 1994, 34% in 1995 to 1998, and 12% in 1999 to 2001. The parents' characteristics did not influence the outcome of pregnancy. Conclusions The relatively low termination rate (28%) in pregnancies where the fetus was affected by SCP and the decreasing termination trend over time in our centre suggest an improved knowledge of the pathological conditions associated with SCP, influencing genetic counselling. Copyright © 2004 John Wiley & Sons, Ltd.

In this review we aimed to update the possibilities of adenomyosis treatment in women excluding those with a desire for pregnancy. Adenomyosis is defined as the presence of endometrial tissue within the myometrium and frequently underestimated. Over the last decades, its pathophysiology has been better known. The diagnosis is essentially based on clinical symptoms like menorrhagia and dysmenorrhea. Transvaginal ultrasound and magnetic resonance imaging are the main tools of the radiologic diagnosis. However, the definitive diagnosis is histological. The most effective treatment remains hysterectomy; however it is expensive, radical and at risk of morbidity compared with medical or surgical conservative management. The literature has reported several series of patients undergoing various treatments, thus allowing different therapeutic options. The levonorgestrel-releasing intrauterine device showed its efficacy alone or in combination with hysteroscopic treatment. Oral progestins, GnRH agonists are useful at short term or in preoperative condition. Some conservative treatments like focused ultrasound therapies or uterus-sparing operative treatment stay under evaluation and seems to be effective. Embolization has been the subject of several studies and must be outlined. Furthermore, several molecules, such as modulators of progesterone receptors and the aromatase inhibitors have been recently studied and are perhaps future treatments.

This study reports the fatty acid composition of subcutaneous adipose tissue in French women with special emphasis on the content of trans fatty acids originating from two main dietary sources, ruminant fats and partially hydrogenated vegetable oils (PHVO). Adipose tissue trans fatty acid levels from 71 women, recruited between 1997 and 1998, were determined using a combination of capillary gas chromatography and silver nitrate thin-layer chromatography. Results indicate that on average cis monounsaturates accounted for 47.9% of total fatty acids, saturates for 32.2%, and linoleic acid for 14.4%. Cis n-3 polyunsaturates represented only 0.7%. Total content of trans fatty acids was 2.32 +/- 0.50%, consisting of trans 18:1 (1.97 +/- 0.49%), trans 18:2 (0.28 +/- 0.08%), and trans 16:1 (0.06 +/- 0.03%). Trans 18:3 isomers were not detectable. The level of trans fatty acids found in adipose tissue of French women was lower than those reported for Canada, the United States, and Northern European countries but higher than that determined in Spain. Therefore, trans fatty acid consumption in France appears to be intermediate between that of the United States or North Europe and that of Spain. Based on the equation of Enig et al., we estimated the mean daily trans 18:1 acid intake of French women at 1.9 g per person. The major trans 18:1 isomer in adipose tissue was delta11 trans, as in ruminant fats. Estimates of relative contribution of trans fatty acid intake were 55% from ruminant fats and 45% from PHVO. This pattern contrasts sharply with those established for Canada and the United States where PHVO is reported to be the major dietary source of trans fatty acids.

Aims To describe a new technique of axillary dissection and evaluate the results. Methods Axillary lymphadenectomy prepared by fat and lymph node suction was performed on 43 patients with breast cancer and uninvolved axilla on physical examination. The mean follow-up was 18 months (range 12–27). After lipolysis and liposuction of the axilla, lymph node dissection was performed by axilloscopy in patients treated with conservative surgery. For patients undergoing modified radical mastectomy, a mastectomy with open axillary dissection was carried out. The axillary space was drained until less than 20 ml of lymphorrhea was being produced per day. Seventeen modified radical mastectomies (group M) and 26 lumpectomies (group L) were performed. Results No injury of muscles, vessels or nerves was observed. An average of 13.6 lymph nodes (8–31) were removed. In group L, the mean number of lymph nodes removed by liposuction, axilloscopy and control incision was 2.5, 5.4 and 4.2, respectively. In group M, the mean number of lymph nodes removed was 14. None of the 589 lymph nodes examined showed any pathological trauma. Fourteen patients (32%) had more than one histologically positive node. The mean quantity of lymphorrhea was 390 ml in group M and 275 ml in group L. The mean duration of drainage was 6 days in group M and 5 days in group L. Four patients had seromas which required punctures. Two patients had shoulder restriction (movements Conclusions Axillary lymphadenectomy prepared by fat and lymph node suction is a reliable and effective procedure. However, it does not appear to be better than standard dissection as regards post-operative complications, except for arm oedema, but this must be confirmed by further studies.

OBJECTIVE: To report long-term cytologic findings after treatment of congenital vaginal aplasia or Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) using progressive traction of the vulvar tissues, or Vecchietti's technique (VT). STUDY DESIGN: In eight women with MRKH, neovaginal smears stained by the Harris-Schorr technique were collected 2-12 years after VT. RESULTS: Eosinophilic superficial cells observed in all cases indicate that the neovaginal epithelium responds to hormonal variations. The presence of Doderlein bacilli (seven cases) suggests that the regional environment of the neovagina is almost the same as that of the normal vagina. Gardnerella vaginalis (one case) and human papilloma virus infection (low grade squamous intraepithelial lesions) (one case) were also observed. CONCLUSION: Neovaginal smears taken after the cicatrization period following construction of a neovagina by VT show a remarkable resemblance to those from normal vaginal mucosa and suggest that these neovaginas are almost the same as normal vaginas.

Uterine fibroids are the commonest benign tumor of the female genital tract. They affect a significant proportion of reproductive aged women and while some women are asymptomatic, fibroids can cause excessive menstrual bleeding, pelvic pressure, and adversely affect reproductive outcomes. Myomectomy is the most suitable surgical option for women who desire preservation of their fertility potential. However, only a selected group of women of childbearing age will benefit from a myomectomy. Furthermore, the consequences of myomectomy on reproductive function have remained controversial. The purpose of this paper is to review the main surgical approaches for myomectomy - hysteroscopic resection, laparoscopic myomectomy and open myomectomy (by laparotomy) - and discuss evidence-based indications for myomectomy in women with fibroids, especially with regards to its impact on reproductive outcomes. A critical review of the literature pertaining to the surgical approaches of myomectomy and the indications for myomectomy was performed, focusing on their impact on fertility and reproductive outcomes. Myomectomy is useful for the treatment of symptomatic fibroids and in selected women with infertility. Symptomatic submucosal fibroids are classically treated by hysteroscopic resection. Symptomatic intramural and subserosal fibroids may be treated by myomectomy, either by laparotomy or laparoscopy depending on their number and size. Prophylactic myomectomy is not recommended for preventing obstetrical complications or the risk of leiomyosarcoma. Although fibroids can have a negative effect on fertility, only the removal of submucosal fibroids has been consistently shown to improve spontaneous fertility or outcomes of assisted reproduction technology.

Cancer Antigen 125 (CA125) and Human Epididymis Protein 4 (HE4) are the most studied ovarian tumor markers. Their diagnostic performance for identification of ovarian cancer are superior to CA19-9, CA72-4, and carcinoembryonic antigen, which are no more recommended for the diagnosis of presumed benign ovarian tumor. HE4 (140 pmol/L) is superior to CA125 (30 U/mL) in terms of specificity and positive likelihood ratio. CA125 and HE4 can be combined into an algorithm ROMA, or associated to clinical information (composite index), biological data (OVA1) or imaging (Risk for Malignancy Index (RMI), LR2). ROMA algorithm is an exponential equation combining plasmatic concentrations of HE4 and CA125. ROMA is more sensitive and less specific than HE4 in predicting epithelial ovarian cancer. ROMA is more accurate in post-menopausal women. The performance of ROMA is lower than the ultrasound model LR2 in differentiating malignant from benign ovarian tumors, whatever the hormonal status. The composite index combining CA125 with a symptoms index (pain, abdominal distension, bloating, difficulty eating) has a good sensitivity in a screening program, but because of a 12% false positive rate, ultrasound is required before management. The RMI algorithm is based on serum CA125, ultrasound findings (septation, solid zones, metastases, ascite, bilaterality) and menopausal status. RMI is less sensitive, but more specific than ROMA or OVA1 for the classification of ovarian masses. The addition of HE4 to RMI seems to be the most accurate. The subjective evaluation of ovarian cysts by sonography and color Doppler is better than ROMA and RMI algorithms, and not affected by the hormonal status.

Post-term pregnancy in the broad ligament is rarely described in the literature. A 33-year-old woman, grava 2 para 1, not followed-up during gestation was admitted at 44 weeks of gestation. The fetus was dead and in transversal position, as shown by ultrasound. A cesarean section was performed and the fetus was extracted from the right broad ligament. The placenta was inserted on the surface of the posterior wall of the uterus. Blood loss was estimated at 1200 mL and the patient received isogroup total blood. There was no major complication.

Since the 1993 French consensus conference on uncomplicated pelvic inflammatory diseases (uPID), new antibiotics appeared and bacterial resistances did evoluate. This methodic analysis of the literature updates different aspects of its treatment. Antibiotherapy must be established early (EL3). Inpatient and intravenous treatment is not superior to outpatient and oral treatment (EL1). Ofloxacine+metronidazole association can be proposed in first intention (EL1). If case of Neisseria gonorrhoeae infection, one ceftriaxone injection must be associated (EL4). All the other antibiotics associations have shown to be efficient except the metronidazole+doxycycline association, which is not indicated (EL2). Two weeks treatment seems to be a sufficient duration. Laparoscopic treatment in first intention is not justified except for diagnostic doubts or unfavorable evolution of the medical treatment (EL4). Neither non-steroidic antiinflamatorries, nor corticosteroids, have been proved to be efficient to decrease the adherence risk in uPID (EL3). Early extraction of an intra uterine device (IUD) allows symptomatologic improvement (EL2). Partners treatment with azithromycin improves the 4 months bacteriologic results (EL2). HIV positive patients do not need specific treatment (EL3).

At present, it is estimated that fibroids may be associated with infertility in 5 to 10% and are possibly the sole cause of infertility in 1 to 3%. Their effects on fertility remain debated. The aim of this review of published studies between January 1990 and November 2010 was to clarify the relation between myoma and fertility, and to assess the role of myomectomy in infertile patients. In assisted reproduction technology and spontaneous conception, hysteroscopic sub-mucous myoma resection increased pregnancy rates. Intramural fibroids appear to decrease fertility, but the myomectomy does not improve assisted reproduction technology and spontaneous fertility. More high-quality studies are needed to conclude toward the value of myomectomy for intramural fibroids. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit.

To define the involvement of myomas and myomectomy in all stages from conception to post-partum in women of reproductive age.A literature review was conducted using the Medline and Cochrane databases to March 2011 by matching the keywords "fertility, infertility, miscarriage, pregnancy, delivery" with "myomas, fibroids, myomectomy".An association between myomas and fertility has been observed but the responsibility fibroids in infertility remains unclear. Myomas are associated with an increased rate of obstetric complications. Adhesions are the main complication of myomectomy. Endoscopic procedures and the use of anti-adhesive barriers prevent adhesion formation. Pregnancy rate in cases of myomectomy by laparotomy and laparoscopy is similar. Myomectomy during pregnancy is exceptionally indicated.The discovery of a uterine myoma needs to consider the responsibility of myomas in infertility, but also its impact on a future pregnancy. The therapeutic management is based on myomectomy but expected benefits must be weighed with potential risks.

Objective The aim of this project was to determine the clinical effectiveness and cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation (EA), and Mirena® (Bayer Healthcare Pharmaceuticals, Pittsburgh, PA, USA) for the treatment of heavy menstrual bleeding. Design Individual patient data (IPD) meta-analysis of existing randomised controlled trials to determine the short- to medium-term effects of hysterectomy, EA and Mirena. A population-based retrospective cohort study based on record linkage to investigate the long-term effects of ablative techniques and hysterectomy in terms of failure rates and complications. Cost-effectiveness analysis of hysterectomy versus first- and second-generation ablative techniques and Mirena. Setting Data from women treated for heavy menstrual bleeding were obtained from national and international trials. Scottish national data were obtained from the Scottish Information Services Division. Participants Women who were undergoing treatment for heavy menstrual bleeding were included. Interventions Hysterectomy, first- and second-generation EA, and Mirena. Main outcome measures Satisfaction, recurrence of symptoms, further surgery and costs. Results Data from randomised trials indicated that at 12 months more women were dissatisfied with first-generation EA than hysterectomy [odds ratio (OR): 2.46, 95% confidence interval (CI) 1.54 to 3.93; p = 0.0002), but hospital stay [WMD (weighted mean difference) 3.0 days, 95% CI 2.9 to 3.1 days; p

Background Normal menstrual periods last 3–6 days and involve blood loss of up to 80 ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80 ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11–13% in the general population and increases with age, reaching 24% in those aged 36–40 years. Investigation A blood count for red cells + platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. Treatment In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.

To assess the efficacy of therapies in menorrhagia related to atypical endometrial hyperplasia, polyps, myoma, adenomyosis and arteriovenous malformation of the uterus.Medline and Cochrane contents were searched to June 2008.Atypical endometrial hyperplasia is classically treated by hysterectomy, but may temporarily regress under hormone therapy (progestins, Gn-RH agonists) in women of childbearing age. Hysteroscopic resection is the standard treatment for endometrial polyps. Recurrence of bleeding is reduced by combining it with endometrial ablation. Myoma-related menorrhagia can be treated by Gn-RH agonists for 3 months or levonorgestrel in utero (LNG-IUS). Hysteroscopic resection is the standard treatment of submucous myomas. Interstitial myomas can be treated by myomectomy, myolysis, uterine artery embolisation or occlusion, or hysterectomy. Laparoscopic myomectomy and uterine artery embolisation are effective, well tolerated, and the best researched. LNG-IUS is effective and well tolerated to treat adenomyosis-related menorrhagia. The effect of other conservative treatments of the uterus (endometrial ablation, uterine artery embolisation or occlusion) is limited, especially in case of deep and extensive adenomyosis. Uterine artery embolisation is the standard treatment for arteriovenous malformation.Numerous medical and technical innovations have been recently developed as conservative treatments for menorrhagia. However, hysterectomy remains the standard treatment of atypical endometrial hyperplasia and adenomyosis.

Human papillomavirus is a necessary cause for the development of cervical cancer. Cervical cancer is attributed to 15 high-risk oncogenic HPV among the 120 genotypes present in human. The infection affects about 3 out of 4 women and is often transient thanks to immunological modulators leading to viral clearance. This characteristic made it possible to develop vaccines. Prophylactic vaccines are made of virus-like particles L1, non infectious, well tolerated and highly immunogenic. They prevent from viral infection by producing antibodies, which are secreted throughout the genital mucosa (humoral immunity). High-risk oncogenic HPV-16 and 18, responsible for 70% of cervical cancer, are included in Gardasil and Cervarix. Both vaccines prevent from HPV infection and related cervical and perineal lesions in more than 90% of the cases. Therapeutic vaccines are made of epitope peptides, recombinant proteins and bacteria, plasmid DNA or dendritic cells. All sensitize immunocompetent cells (cellular immunity). Ineffective in cervical cancers, they induce the regression of cervical dysplasia in about 50% of the cases. They are still under research and development, in opposition to prophylactic vaccines, which are available.

Endometrial hyperplasias can be divided into two categories based on the presence or absence of cytological atypia and further classified as simple or complex according to the extent of architectural abnormalities. They are usually diagnosed because of irregular bleeding in perimenopause. Hysteroscopy with a biopsy gives a more accurate diagnosis than transvaginal ultrasonography, sonohysterography, or blind curettage. Endometrial hyperplasias with no cytological atypia, regarded as a response to unopposed endogenous estrogenic stimulation, are normally treated with progestins. The intra-uterine route (levonorgestrel intra-uterine system) is more effective and better tolerated than the oral route. Either conservative surgery (endometrial resection, thermal ablation) or radical surgery (hysterectomy) in the case of other genital diseases is performed on women who did not respond to medical treatment. Endometrial hyperplasias with cytological atypia, considered as intra-epithelial neoplasias, are traditionally treated by hysterectomy. The absence of management protocols in the literature offers various treatment options and indications. Gonadotropin-releasing hormone agonists, danazol, or aromatase inhibitor are effective, but have adverse effects and are expensive. Endometrial ablation can be performed as a first line therapy in women suffering from bleeding related to hyperplasia without cytological atypia. Medical treatment may be offered to young women suffered from hyperplasias with cytological atypia and desiring pregnancy.

Objectives To evaluate the feasibility, accuracy and safety of chorionic villus sampling (CVS). Methods Ten thousand seven hundred and forty one singleton pregnancies at risk of chromosome abnormalities (96.3%) and gene disorders (2.8%) were referred from 1990 to 1999 to the fetal medicine unit of a teaching hospital. CVS was performed transabdominally after 11 weeks, using a modified freehand ultrasonographically guided technique by 5 operators. Fetal karyotyping was obtained using a direct method before 1995 and was completed by cell culture after 1996. Failed results, feto-placental discrepancy and fetal loss were assessed. Results Villi were sampled using extra-amniotic puncture (89.4%) and one sampling-device insertion (92.3%). The mean weight of the specimen was 15.2 ± 6.0 mg. All attempts at sampling were successful, except eight (0.07%). The number of failed results following direct preparation, cell culture and both methods was 20 (0.19%), 23 (0.21%) and 2 (0.02%), respectively. Light maternal cell contamination occurred in less than 1% of the samplings after microscopic selection of the villi, and never interfered with the assessment of karyotyping. All 3 false-negative results (0.03%) were recorded after direct preparation and 2 were corrected by culture. The rate of chromosomal abnormalities confined to the placenta decreased from 1.08% before 1995 to 0.73% after 1996. True fetal mosaicisms were recorded in 7 cases (0.06%). The rate of fetal loss at

To assess complications and after-effects of conizations and follow-up of patients treated with 3 conization methods. Materials and methods. Two hundred and forty-one conizations were performed for cervical dysplasia using cold knife (100 cases), electric knife (39 cases) or loop electrosurgical excision (102 cases). Residual disease, post-operative bleeding, cervical stenosis and recurrences were assessed.The height of the cone biopsy specimen was higher after cold knife conization (18.3 4.7 mm) and electric knife conization (18.4 0.7 mm) than after loop electrosurgical excision (12.8 3.5 mm) (P0.001). However, the rate of positive margins for dysplasia was not significantly different: 7%, 8% and 14%, respectively. The rate of post-operative bleeding was 8%, 5% and 2%, respectively. The rate of cervical stenosis was 8%, 27% and 3%, respectively (P0.001). The rate of recurrences was not significantly different: 8%, 15% and 11%, respectively.Taking into account the current trend not to repeat surgery systematically after positive margin conizations, the risk of bleeding after cold knife conization, the risk of stenosis after electric knife conization and excessive depth of cone excision, the loop electrosurgical procedure may be recommended as a first option to treat cervical dysplasia.

The synthetic pentasaccharide, fondaparinux, is the first of a new antithrombotic class: selective factor Xa inhibitors. Comparative clinical trials of fondaparinux versus heparins in prevention and treatment of venous thromboembolism are ongoing. Little is known about fondaparinux during pregnancy, as women of child-bearing potential were excluded from clinical trials. No particular safety issue, for either mother or fetus, has been reported for heparins. The objective of this study was to compare in vitro the steady state placental transfer of fondaparinux and enoxaparin at the plasma concentrations reached during acute treatment of venous thromboembolism (1.75 microg/mL and 1 anti-Xa IU/mL respectively), using antipyrine (20 mg/L) as reference. No biological activity was detectable in the fetal venous effluent during perfusion of enoxaparin-antipyrine, fondaparinux-antipyrine or control media. Furthermore, fetal venous samples did not differ significantly from fetal arterial samples. This apparent absence of placental transfer supports further evaluation of fondaparinux in pregnant women.

Endometrial hyperplasias are mainly regarded as a response to unopposed endogenous estrogenic stimulation and concern 12% of perimenopausal women. They are usually diagnosed because of irregular bleeding. They are divided into two categories based on the presence or absence of cytological atypia and further classified as simple or complex according to the extent of architectural abnormalities. Endometrial hyperplasias with cytological atypia are classically treated by hysterectomy. Endometrial hyperplasias without cytological atypia are classically treated by progestins. The bad observance (25% spontaneously stopping), the 30% recurrence rate after stopping progestin and the 12-53% resistance rate to treatment lead to propose a second-line therapy after endocrinological check-up, exploration of haemostasis, pelvic ultrasonography, hysteroscopy and endometrial biopsies. Standard treatments include uterine curettage which is not very effective and hysterectomy. Medical alternatives (gonadotropin-releasing hormone agonists, levonorgestrel-releasing intrauterine device) and surgical alternatives (endometrial resection, thermal balloon endometrial ablation) were developed to avoid treating functional pathology radically. These conservative procedures correct 80% of endometrial hyperplasia symptoms with a low rate of lateral effects. However, these results need to be confirmed by long-term studies. Some economical, legal or material factors can also limit carrying out the procedures. Clinical trials need to be performed to better define the place of medical and surgical alternatives to hysterectomy in the treatment of endometrial hyperplasias resistant to progestins.

Most of symptomatic functional ovarian cysts (FOC) are treated by surgery. Oral contraceptives and ultrasound-guided puncture are not more efficient than expectant management for treating asymptomatic FOC in non menopausal women. The probability of a cyst being functional or benign in asymptomatic postmenopausal women is assessed by transvaginal ultrasonography, color Doppler flow imaging and CA 125 serum level measurement. Conservative management of simple cysts (anechoic, diameter5 cm with normal Doppler and CA 125 serum level) is more reasonable and safer than surgical treatment. The use of high-dose combination oral contraceptives has a protective effect against FOC, whereas low-dose pills have little or no effect. However, low-dose oral contraceptives or progestogen-only oral contraceptives do not increase the risk of FOC. In the case of recurrent or symptomatic FOC, the advantages of using higher dose formulations have not been proved. Expectant management is as effective as oral contraceptives for the resolution of FOC induced by ovarian stimulation. Tamoxifen treatment in premenopausal breast cancer patients is associated with ovarian overstimulation and FOC formation (35%). Co-treatment with Gn-RH agonist may be successful in this indication. Hormone replacement therapy may be associated with an increasing ovarian volume, but not with an increasing rate of FOC. The management of surgical-induced FOC (entrapped ovarian cyst, ovarian transposition) has never been assessed by controlled studies.

Thermal balloon endometrial ablation is indicated for women suffering from menorrhagia. This easy technique can be performed safely, without using operative hysteroscopy. The rate of minor complications is low (4%). Thermotherapy treats the endometrium and superficial myometrium tissues without risk of injury to the bladder and bowels. The success rate of this operation is 90% in selected patients of studies published between 1996 and 1998, with a follow-up period of 12-24 months. However, long-term randomized controlled studies are needed to compare thermotherapy and other endometrial ablation procedures.

To describe a population of high risk pregnancies transported to a regional perinatal care centre (level III) and to analyze the advantages and limitations of the organization of this perinatal care network.Retrospective study of 263 patients transported to the University Hospital of Bordeaux between September 1996 and September 1998.Maternal transport mainly came from the Gironde department (53%) and from level I care hospitals (66%). The rate of multiple pregnancies was 17%. Principal indications were preterm labor with or without rupture of fetal membranes (52%) and preeclampsia with or without intrauterine growth restriction (28%). The rate of returns to the referring care centre was 2%. The mean term at delivery was 32 WA. Forty-one percent of patients delivered within 24 hours of transport. The rate of caesarean sections was 55%. There were 303 live births. The mean duration of hospitalization of the neonates was 28 days. The rate of perinatal mortality was 6.2%. Among the 96 pregnancies beyond 32 WA, 17 (6.5%) could have been transported to some level IIb care hospitals, nearby the patient's residence, without changing maternal and neonatal prognosis. Neonatal mortality was not significantly different for maternel transport (18%) or neonatal transport (14%) in the group of premature infants born prior to 31 WA in our study.Our organization is currently trying to improve transport management (non-emergency situations, collaboration of level II care hospitals) and to increase the rate of returns to the referring care centres.

To evaluate survival and assess prognostic factors in patients with epithelial ovarian cancer.Retrospective analysis of 287 patients treated between 1975 and 1995. All operations were performed by senior surgeons. Histologic sections were reviewed by the same pathologist. Successive adjuvant chemotherapy regimens are described. Survival was evaluated in 1997. Follow-up lasted 25-260 months (median 90). Statistical methods included Kaplan-Meier survival curves, logrank test and multivariate analysis.The five-year survival rates 76%, 42%, 21% and 6% for patients with stage I, II, III and IV disease, respectively. Age, FIGO stage, cytology of ascites, histologic type and grade, extent of surgery and number of residual tumors were significant prognostic indicators in univariate analysis. Multivariate analysis showed that the risk of mortality was reduced by 57% for patients whose tumor distribution permitted optimal surgery (RR = 0.43, 95% CI [0.29-0.64]; P0.001). The risk of mortality according to FIGO stage was 2.8 (95% CI [1.2-6.3]; P = 0.01) for FIGO II, 5.6 (95% CI [2.9-10.8]; P0.001) for FIGO III and 10.5 (95% CI [4.9-22.1]; P0.001) for FIGO IV in comparison with FIGO I. The risk of mortality for patients treated with alkylating agents, platinum-based combination chemotherapy taxanes or carboplatin plus paclitaxel regimen compared with patients who did not receive treatment was reduced by 47% (95% CI [8%-69%]; P = 0.025), 55% (95% CI [22%-74%]; P = 0.005) and 70% (95% CI [35%-86%]; P = 0.002), respectively. Patients with a serous epithelial carcinoma had a 1.7-fold higher risk of mortality than patients with other histologic types (RR = 1.7, 95% CI [1.1-2.8]; P = 0.02).Our study confirms the benefit of cytoreductive surgery and the efficacy of platinum plus paclitaxel first-line chemotherapy, which has recently been recognized as the standard treatment for advanced epithelial ovarian cancer.

Urinary incontinence in elderly women, though due to several factors, is not inevitable; case-by-case management is often effective.

To study the prevalence of Cervical Intraepithelial Neoplasia (CIN) and its association with HIV-I infection, controlling for other risk factors of CIN.Cross-sectional survey.HIV-1 seropositive (HIV+) and seronegative (HIV-) women were enrolled at the Obstetrics-Gynecologic Departments of the Bordeaux University Hospital from April 1993 to June 1995. A gynecologic check-up was performed with a clinical examination, a colposcopy and a Papanicolaou smear. Sexually Transmitted Diseases (STDs) were screened. Colposcopy was interpreted as: normal, low-grade or high-grade lesions. Interpretation of Papanicolaou smears was based on the 1988 Bethesda system using three descriptive diagnoses: normal, low-grade and high-grade Squamous Intraepithelial lesions (SILs). If colposcopy showed a high grade lesion or Papanicolaou smear a high-grade SIL, a cervical biopsy was performed. Absence of CIN was defined by normal Papanicolaou smear and colposcopy. High grade CIN was defined by either identification of high grade SIL on Papanicolaou smear or high grade lesion on colposcopy confirmed by CIN2-3 lesion on biopsy. Other cases were classified as low-grade CIN. HPV infection was diagnosed on presence of koilocytosis on cytological or histological specimens.Prevalence of CIN was significantly higher in the 128 HIV+ women than in the 102 HIV- women: 34.4% vs. 13.7% (O.R.=3.30). Among HIV+ women, 25.8% had low-grade CIN and 8.6% high-grade CIN versus 10.8% and 2.9%, respectively among the HIV- women. Prevalence of HPV infection was 50.0% among women with CIN vs. 5.8% in women without CIN (P= 10(-6)). In the multivariate analysis of the determinants of CIN, smoking more than ten pack-years and HPV infection were the only two variables associated with CIN while association with HIV infection disappeared. Among HIV+ women, the variables associated with CIN were clinical AIDS and HPV infection.

To describe a teaching method for students in gynecological semeiology and evaluate the results.Theoretical and practical aspects of the course were designed to meet a set of objectives. Theoretical teaching included one or two objectives per class. Clinical examination was initially taught on an anatomical mannikin, then on a patient under general anesthetic. Students were evaluated after four 3-hour classes by means of multiple choice questions (MCQ) and a clinical case report. The course was evaluated by means of a questionnaire, asking the students for their opinion.Twenty-five students out of 31 were tested in 1995-1996. The MCQ results were good with 84% correct answers (78% for first cycle and 89% for second cycle students). It was not possible to assess the clinical case report. The students appreciated the scientific and educational quality of the course, but felt that the sessions were too short and too infrequent.This teaching method for students in gynecological semeiology was successful in its first year of application. This experiment may result in the development of a course combining university teaching and practical work leading to a common theory/practical examination.

Vulvar vestibulitis syndrome is defined as chronic vulvar erythema involving dyspareunia. Some infectious causes have been suggested, as human papillomavirus. Other known or suspected causes include use of chemicals or other irritants. Sexual active women of the third decade are classically exposed to this syndrome. Dyspareunia is complex with a neurophysiological cause and an emotional outcome. Patients require a medical, surgical or psychological follow-up according to each case.

To determine the pathological features of lymph nodes removed by axillary liposuction.A prospective study of 34 axillary dissections performed from July 1995 to September 1996 in patients with breast cancer N0. After lipolysis, the fat was drained from the axillary cavity by means of liposuction (Karman nozzle ch.8; suction pressure of 1 Bar). The remaining nodes were removed by an endoscopic dissection in conservative treatments. The remaining nodes were removed during modified radical mastectomy in non-conservative treatments. Lymph nodes were fixed in formol and examined by the pathologist.An average of 15 lymph nodes (8-35) were removed. 502 lymph nodes were examined: 458 (91%) were not involved and 44 (9%) were involved, including 21 (4%) with rupture of the capsule. No pathological traumatism was seen.Axillary liposuction did not alter the pathological features of lymph nodes in our study.

Malformations of the uterus result from a variety of anomalies during embryogenesis from the 6th to the 17th week of development. Agenesia (not discussed here) should be distinguished from unicornis, pseudo-unicornis, bicornis, bipartitus and communicating uteri (Musset's classification). Such malformations occur in 3 to 4% of all women. Sonography provides the most useful information for diagnosis and should be used as first intention examination together with a work-up to determine extension. In certain cases, hysterography and laparoscopy may be required. Sterility is not increased in women with a malformation of the uterus, but fecundity is reduced due to a high rate of spontaneous abortions (30 to 40%) and premature births (15 to 45%). Obstetrical prognosis in case of a partitioned uterus can be improved by hysteroscopic resection of the partition. Most authors propose endoscopic treatment when a malformation of the uterus is diagnosed during a sterility work-up.

The author reports some review articles about post-operative lymphocele in gynecological and breast cancer surgery. Post-operative sonography often shows an increased incidence of this complication which is unsuspected with only physical examination. Curative treatment of the postoperative lymphocele is performed by puncture, drainage or excision if lymphocysts become fibrous. Preventive treatment after lymphadenectomy is performed by padding of the axilla after breast cancer surgery or visceral non-peritonization after extended lymphadeno-colpohysterectomies. There is no real solution to prevent lymphocele after inguinal lymphadenectomy.

We report the case of a 41-year-old ASA I patient who experienced during endometrial resection a transient idioventricular cardiac rhythm with hypotension related to a major glycine intoxication. The total volume of absorbed irrigating fluid was over six liters when these clinical signs occurred. The biological data were as following: Na = 89 mmol.L-1, Cl = 60 mmol.L-1 and osmolarity = 215 mOsm.L-1. Simultaneously, the glycine concentration in the plasma was 54.6 mmol.L-1, i.e 160 times higher than the normal value. The clinical course was unremarkable except vomiting. The treatment included only the administration of a diuretic agent, as the correction of the disorder took place spontaneously. The paucity of clinical symptoms when compared to the severity of the biological disorders explain why preventive measures are essential in this type of surgery.

A case of antenatal hydrothorax was observed. The aetiology could not be determined before birth. At birth an extra-lobe lung sequestation was treated surgically after 3 weeks in the intensive care unit. The surgical cure was successful with no sequellae. This favourable outcome is unusual in this type of pathology and can be explained by the fact that the sequestration was isolated in a fetus with only minimal anasarca. Indications for prenatal pleural drainage are discussed.

Determine the pathogenesis of fetal nuchal oedema and cystic hygromas of the neck and establish prenatal prognosis factors.Retrospective study of 49 cases including 35 early diagnoses (10 to 14 weeks gestation) and 14 late diagnosis (after 15 weeks). Chorial villosity biopsy was performed for fetal karyotype.The global rate of genetic or chromosomic abnormalities in the fetuses was 47%. The fetuses with nuchal associated with other echographic anomalies had a high risk of chromosomic aberrations (80%). Fetuses with nuchal oedema alone during the first trimester had a higher risk of trisomy 21 proportionally with the age of the mother and paradoxically no trisomy 21 was found in women under 30 years of age. When early nuchal oedema regressed spontaneously in an euploid fetus, echographic surveillance can be proposed to detect possible polymalformation syndromes discovered late. Cystic hygromas of the neck were diagnosed from 15 weeks gestation and were always pathologic.Interpreting nuchal images in the fetus must take into account the echographic term at discovery and its isolated or associated nature. Further studies are needed to determine indications for chorial villosity biopsy in mothers under 30 with a fetus with isolated nuchal oedema which regresses spontaneously during the first trimester.

During a 4-year period, 29 fetal nuchal edemas were observed, associated with other ultrasound abnormalities in 7 cases (24%). Fetal karyotypes were abnormal in 10 cases: 6 trisomy 21; 3 trisomy 18, and 1 Turner's syndrome. Isolated fetal nuchal edema was associated with aneuploidy in 4 cases: 3 trisomy 21, and 1 trisomy 18. The average age of the women carrying a fetus with nuchal edema associated or not with a trisomy 21 was 38.3 and 30.8 years, respectively. These results are similar to those found in the literature. It would appear that maternal age is a better marker in trisomy 21 screening than isolated fetal nuchal edema.

To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding.Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction.Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment.At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis.More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.