RESUMO

ABSTRACT BACKGROUND: Abnormal uterine bleeding (AUB) is a common condition, and the Menstrual Bleeding Questionnaire (MBQ) is used for its assessment. OBJECTIVES: To translate, assess the cut-off point for diagnosis, and explore psychometric properties of the MBQ for use in Brazilian Portuguese. DESIGN AND SETTING: Prospective cohort study including 200 women (100 with and 100 without AUB) at a tertiary referral center. METHODS: MBQ translation involved a pilot-testing phase, instrument adjustment, data collection, and back-translation. Cut-off point was obtained using receiver operating curve analysis. Menstrual patterns, impact on quality of life due to AUB, internal consistency, test-retest, responsiveness, and discriminant validity were assessed. For construct validity, the Pictorial Blood Assessment Chart (PBAC) and World Health Organization Quality of Life - abbreviated version (WHOQOL-BREF) were applied. RESULTS: Women with AUB were older, had higher body mass indices, and had a worse quality of life during menstruation. Regarding the MBQ's psychometric variables, Cronbach's alpha coefficient was > 0.70 in all analyses, high intraclass correlation coefficient was found in both groups; no ceiling and floor effects were observed, and construct validity was demonstrated (correlation between MBQ score, PBAC score, and clinical menstrual cycle data). No difference between MBQ and PBAC scores were perceived after the test-retest. Significant differences were found between MBQ and PBAC scores before and after treatment. An MBQ score ≥ 24 was associated with a high probability of AUB; accuracy of 98%. CONCLUSION: The MBQ is a reliable questionnaire for Brazilian women. The cut-off ≥ 24 shows high accuracy to discriminate AUB.

RESUMO

Endometrial ablation (EA) is a minimally invasive surgical procedure to reduce abnormal uterine bleeding contemplated for women who have achieved their reproductive goals. EA consists of the destruction of the endometrial layer with preservation of the uterus, although EA has lower complication rates than hysterectomy, it may be associated with metrorrhagia recurrence. One of the major causes of treatment failure is incomplete ablation of the endometrium. Thanks to techniques that have been developed in recent years, endometrial ablation can be performed on an outpatient basis, including by radiofrequency ablation. The main objective of this case series was to report four cases in which Radiofrequency Endometrial Ablation (RFEA) was used to treat abnormal uterine bleeding at a single ambulatory surgical center in Brazil. Hysteroscopic evaluation of the uterine cavity was performed immediately prior to the RFEA to diagnose possible endometrial pathologies and again at the conclusion of the procedure to assess the aspect of the newly treated endometrium. Verification of the completeness of the ablation was assessed by a third hysteroscopy 30 or 60 days after the ablation. In this case series RFEA was efficacious and safe for outpatient use. Although radiofrequency endometrial ablation can be performed without the use of the hysteroscope, we believe it is an important tool for the timely verification of the completeness of the endometrial ablation. (AU)

A ablação endometrial (AE) é um procedimento cirúrgico minimamente invasivo destinado a mulheres com prole estabelecida visando redução do sangramento uterino anormal. A AE consiste na destruição da camada endometrial com a preservação do útero, apesar da AE possuir menores índices de complicação do que a histerectomia, pode estar associada a recorrência do sangramento. Uma das causas da falha de tratamento é a ablação incompleta do endométrio. Atualmente, a ablação endometrial pode ser realizada ambulatorialmente graças às técnicas que vêm sendo desenvolvidas nos últimos anos, as quais incluem o uso de radiofrequência. O objetivo dessa série de casos é descrever 4 casos de Ablação Endometrial por Radiofrequência (AERF) para o tratamento de sangramento uterino anormal realizados em um mesmo ambulatório especializado no Brasil. Uma avaliação histeroscópica da cavidade uterina foi realizada imediatamente antes da AERF para diagnosticar possíveis patologias endometriais e imediatamente ao final do procedimento, para avaliar o aspecto do endométrio recém tratado e a necessidade de nova aplicação de radiofrequência. A integralidade da ablação foi verificada por uma terceira histeroscopia após 30 ou 60 dias depois da ablaçao. A técnica mostrou-se adequada para uso ambulatorial. Embora a ablação endometrial por radiofrequência possa ser realizada sem o uso do histeroscópio, acreditamos que seja uma ferramenta importante para a verificação oportuna da integralidade da ablação endometrial. (AU)

RESUMO

O sangramento uterino anormal é diagnóstico sindrômico comum no consultório do ginecologista e pode comprometer substancialmente a qualidade de vida. O objetivo no diagnóstico de sangramento uterino anormal é distinguir pacientes com causas estruturais (anatômicas), como pólipo, adenomiose, leiomioma, malignidade e hiperplasia, de pacientes que apresentam anatomia normal, nas quais o sangramento pode ser devido a alteração dos mecanismos de coagulação, distúrbios ovulatórios, distúrbios primários do endométrio, iatrogenia, ou ter outra causa não classificada. O diagnóstico se inicia a partir de anamnese detalhada e exame físico geral e ginecológico completos, seguidos da solicitação de exames complementares (laboratoriais e de imagem), conforme indicado. O exame de imagem de primeira linha para identificação das causas estruturais inclui a ultrassonografia pélvica. Histerossonografia, histeroscopia, ressonância magnética e amostragem endometrial para exame de anatomia patológica são opções que podem ser incluídas no diagnóstico a depender da necessidade. O objetivo deste artigo é apresentar a relevância dos exames de imagem na investigação das causas de sangramento uterino anormal.

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office and may substantially affect quality of life. The aim in the diagnosis of abnormal uterine bleeding is to distinguish women with anatomic causes such as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia from women with normal anatomy where the cause may be coagulopathy, ovulatory disorders, endometrial, iatrogenic and not otherwise classified. Diagnosis begins with a thorough history and physical examination followed by appropriate laboratory and imaging tests as indicated. The primary imaging test for the identification of anatomic causes include ultrasonography. Saline infusion sonohysterography, magnetic resonance, hysteroscopy, endometrial sampling are options that can be included in the diagnosis depending on the need. The aim of this article is to present the relevance of imaging exams in the investigation of the causes of abnormal uterine bleeding.

Assuntos

RESUMO

Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Os miomas uterinos são os tumores ginecológicos benignos mais comuns em mulheres em idade reprodutiva, sendo a ultrassonografia a modalidade de imagem de primeira linha para seu diagnóstico e caracterização. A Federação Internacional de Ginecologia e Obstetrícia desenvolveu um sistema para descrever e classificar os miomas uterinos de forma uniforme e consistente. Uma descrição precisa dos miomas no laudo ultrassonográfico é essencial para o planejamento do tratamento cirúrgico e prevenção de complicações. Neste artigo, revisamos os achados ultrassonográficos de miomas, detalhando os principais pontos a serem relatados para avaliação pré-operatória. Além disso, propomos um modelo de relatório estruturado e ilustrado para descrição de miomas, com base nos pontos críticos para o planejamento cirúrgico.

RESUMO

Abstract Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Resumo Os miomas uterinos são os tumores ginecológicos benignos mais comuns em mulheres em idade reprodutiva, sendo a ultrassonografia a modalidade de imagem de primeira linha para seu diagnóstico e caracterização. A Federação Internacional de Ginecologia e Obstetrícia desenvolveu um sistema para descrever e classificar os miomas uterinos de forma uniforme e consistente. Uma descrição precisa dos miomas no laudo ultrassonográfico é essencial para o planejamento do tratamento cirúrgico e prevenção de complicações. Neste artigo, revisamos os achados ultrassonográficos de miomas, detalhando os principais pontos a serem relatados para avaliação pré-operatória. Além disso, propomos um modelo de relatório estruturado e ilustrado para descrição de miomas, com base nos pontos críticos para o planejamento cirúrgico.

RESUMO

SUMMARY OBJECTIVE: This study aimed to comparatively evaluate the presence of abnormal uterine bleeding and associated factors among women from the five official Brazilian geographic regions. METHODS: This is a cross-sectional, population-based, multicenter study of reproductive-age women from the five regions of Brazil. All participants answered questionnaires containing personal and socioeconomic data and information on uterine bleeding (self-perception and objective data). RESULTS: A total of 1,761 Brazilian women were included, 724 from the Southeast, 408 from the Northeast, 221 from the South, 213 from the North, and 195 from the Central-West. Considering women's self-perception, the prevalence of abnormal uterine bleeding was 37.56% in the North region, 39.46% in the Northeast, 21.54% in the Central-West, 29.56% in the Southeast, and 25.34% in the South (p<0.001). Abnormal uterine bleeding was more prevalent in the North and Northeast, where women had lower purchasing power, became pregnant more often, and were the only ones financially responsible for supporting the family more often (p<0.001). The menstrual cycle lasted <24 days in less than 20% of the women in all regions (p=NS). Among these, approximately 8 out of 10 women had never undergone treatment in four out of the five regions evaluated. More than half of the evaluated women reported a worsening of their quality of life during bleeding. CONCLUSION: The prevalence of abnormal uterine bleeding in Brazilian women was higher in the North and Northeast, followed by the Southeast, South, and Central-West regions. There was a worsening of quality of life during menstruation regardless of the woman's self-perception of abnormal uterine bleeding. Such results can direct the actions of health managers toward a better approach to abnormal bleeding.

RESUMO

OBJECTIVE: To compare the diagnostic performance of two-dimensional transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH) for the diagnosis of endometrial polyps in studies that used both tests in the same group of patients. METHODS: This was a systematic review and meta-analysis. An extensive search was conducted of Medline (PubMed), Cochrane Library and Web of Science, for studies comparing the diagnostic performance of TVS and SCSH for identifying endometrial polyps, published between January 1990 and December 2019, that reported a definition of endometrial polyp on TVS and SCSH and used pathologic analysis as the reference standard. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A random-effects model was used to determine pooled sensitivity, specificity and positive and negative likelihood ratios of TVS and SCSH in the detection of endometrial polyps. Subanalysis according to menopausal status was performed. RESULTS: In total, 1278 citations were identified; after exclusions, 25 studies were included in the meta-analysis. In the included studies, the risk of bias evaluated using QUADAS-2 was low for most of the four domains, except for flow and timing, which had an unclear risk of bias in 13 studies. Pooled sensitivity, specificity and positive and negative likelihood ratios for TVS in the detection of endometrial polyps were 55.0% (95% CI, 46.0-64.0%), 91.0% (95% CI, 86.0-94.0%), 5.8 (95% CI, 3.9-8.7) and 0.5 (95% CI, 0.41-0.61), respectively. The corresponding values for SCSH were 92.0% (95% CI, 87.0-95.0%), 93.0% (95% CI, 91.0-95.0%), 13.9 (95% CI, 9.9-19.5) and 0.08 (95% CI, 0.05-0.14), respectively. Significant differences were found when comparing the methods in terms of sensitivity (P < 0.001), but not for specificity (P = 0.0918). Heterogeneity was high for TVS and moderate for SCSH. On subanalysis according to menopausal status, SCSH was found to have higher diagnostic accuracy in both pre- and postmenopausal women; sensitivity and specificity did not differ significantly between the groups for either TVS or SCSH. CONCLUSION: Given that SCSH has better diagnostic positive and negative likelihood ratios than does TVS in both pre- and postmenopausal women, those with clinical suspicion of endometrial polyps should undergo SCSH if TVS findings are inconclusive. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ecografía transvaginal bidimensional vs histerosonografía con contraste salino para el diagnóstico de pólipos endometriales: revisión sistemática y metaanálisis OBJETIVO: Comparar el desempeño del diagnóstico de la ecografía transvaginal bidimensional (TVS, por sus siglas en inglés) y la histerosonografía con contraste salino (SCSH, por sus siglas en inglés) para el diagnóstico de pólipos endometriales en estudios que utilizaron ambas pruebas en el mismo grupo de pacientes. MÉTODOS: Este estudio fue una revisión sistemática y metaanálisis. El estudio realizó una extensa búsqueda en Medline (PubMed), Cochrane Library y Web of Science de estudios en los que se había comparado el desempeño del diagnóstico de la TVS y la SCSH para identificar pólipos endometriales, publicados entre enero de 1990 y diciembre de 2019, que incluyeran una definición de pólipo endometrial en la TVS y la SCSH y utilizaran el análisis patológico como estándar de referencia. La calidad de los estudios incluidos se evaluó mediante la herramienta de Evaluación de Calidad de los Estudios de Precisión en el Diagnóstico-2 (QUADAS-2, por sus siglas en inglés). Se utilizó un modelo de efectos aleatorios para determinar la sensibilidad combinada, la especificidad, los cocientes de verosimilitud positivos y negativos de la TVS y la SCSH en la detección de pólipos endometriales. Se realizó un subanálisis en función del estatus de la menopausia. RESULTADOS: Se identificaron un total de 1278 citas, de las cuales se incluyeron 25 estudios en el metaanálisis. En los estudios incluidos, el riesgo de sesgo evaluado mediante QUADAS-2 fue bajo para la mayoría de los cuatro dominios, excepto para el flujo y el tiempo, que tuvieron un riesgo de sesgo poco claro en 13 estudios. La sensibilidad combinada, la especificidad y los cocientes de verosimilitud positivos y negativos para la TVS en la detección de pólipos endometriales fueron del 55,0% (IC 95%, 46,0-64,0%), 91,0% (IC 95%, 86,0-94,0%), 5,8 (IC 95%, 3,9-8,7) y 0,5 (IC 95%, 0,41-0,61), respectivamente. Los valores correspondientes para la SCSH fueron 92,0% (IC 95%, 87,0-95,0%), 93,0% (IC 95%, 91,0-95,0%), 13,9 (IC 95%, 9,9-19,5) y 0,08 (IC 95%, 0,05-0,14), respectivamente. Se encontraron diferencias significativas al comparar los métodos respecto a la sensibilidad (P<0,001), pero no respecto a la especificidad (P=0,0918). La heterogeneidad fue alta para la TVS y moderada para la SCSH. En el subanálisis según el estado menopáusico, se determinó que la SCSH tenía una mayor precisión en el diagnóstico en las mujeres pre- y posmenopáusicas, mientras que la sensibilidad y la especificidad no difirieron significativamente entre ambos grupos, tanto para la TVS como para la SCSH. CONCLUSIÓN: Dado que la SCSH tiene mejores coeficientes de verosimilitud positivos y negativos de diagnóstico que la TVS en las mujeres pre- y posmenopáusicas, las mujeres con sospecha clínica de pólipos endometriales deberían someterse a una SCSH si los hallazgos de la TVS no son concluyentes.

Assuntos

RESUMO

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Assuntos

RESUMO

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Assuntos

RESUMO

La enfermedad trofoblástica gestacional (ETG) constituye un conjunto heterogéneo de afecciones malignas y benignas derivados de la proliferación anormal del trofoblasto o de las células germinales de ambos sexos. La ETG tiene una incidencia variable a lo largo del mundo. A nivel nacional, no se han realizado estudios de caracterización epidemiológica de esta población y, frecuentemente, los datos manejados están basados en estudios extranjeros. Objetivo: Determinar las características clínicas y epidemiológicas de las pacientes diagnosticadas con embarazo molar en el período transcurrido entre el año 2012 y 2019, en el hospital Clínico Herminda Martin de Chillán. Materiales y métodos: Estudio observacional transversal de serie temporal, se consideró el número total de fichas clínicas del Hospital Clínico Herminda Martin de Chillán durante los años 2012 al 2019, con diagnóstico confirmado de Embarazo Molar. Los datos se registraron en la hoja de recolección de datos elaborada, realizándose los análisis estadísticos pertinentes. Resultados: Se analizaron 44 pacientes, la edad promedio de presentación fue de 30.96 años. Los principales síntomas de consulta fueron metrorragia 52.27% (n=23) y dolor abdominal 20.45% (n=9). El principal tratamiento efectuado fue aspiración y legrado en un 77,27% (n=34). El 4.54% (n=2) presentó recurrencia, presentando un segundo episodio de embarazo molar. Conclusiones: El embarazo molar es una patología poco frecuente, pero es un diagnóstico diferencial a tener en cuenta, sobre todo cuando nos enfrentamos a mujeres en edad fértil que consultan por metrorragia o dolor abdominal.

Gestational trophoblastic disease (GTS) is a heterogeneous group of malignant and benign conditions derived from abnormal proliferation of the trophoblast or germ cells of both sexes. GTS has a variable incidence throughout the world. Nationally, no epidemiological characterization studies have been carried out for this population and, frequently, the data handled is based on foreign studies. Objective: To determine the clinical and epidemiological characteristics of patients diagnosed with molar pregnancy between the period between 2012 and 2019 at the Hospital Clinico Herminda Martin of Chillan. Materials and methods: Retrospective observational descriptive cross-sectional study, considering the pregnancies registered at the Hospital Clinico Herminda Martin of Chillan during the years 2012 to 2019, with a confirmed diagnosis of Molar Pregnancy, as sample of study. The data were recorded on the prepared data collection sheet, performing the relevant statistical analyzes. Results: 44 patients were analyzed, the average age of presentation was 30.96 years. The main symptoms of consultation were metrorrhagia 52.27% (n = 23) and abdominal pain 20.45% (n = 9). The main treatment was aspiration and curettage in 77.27% (n = 34). 4.54% (n = 2) presented recurrence, presenting a second episode of molar pregnancy. Conclusions: Molar pregnancy is a rare pathology, but it is a differential diagnosis to take into account, especially when we are faced with women of childbearing age who consult due to bleeding or abdominal pain.

Assuntos