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GYN: 2 casesFrom: Joanne Bulley, MD (islesannie@yahoo.com)Sun Mar 19 11:02:18 2006
First - follow up on my patient with the not perfectly normal US and CA 125 of about 100. Laparoscopy - probably slowly resolving corpus luteum. Ovarian biopsies- one corpus lutem - the other normal. Hyseteroscopy with resection and D&C: leiomyoma and adenomyosis (suspecting these cause the CA 125 of 100) Sent for Familial genetics based on Ov CA, Breast CA and colon CA. New cases - looking for that "collective wisdom" of the years of practice represented here! Case 1. What would you do for post radiation vaginal fibrosis? 36 yo G2P1103. Following her pregnancy with twins she was found to have invasive cervical CA (I was not taking care of her during this time). 4 cm fungating lesion. Had exploratory-lap to see if could treat with radical hysterectomy but a lymph node was supicious so the ovaries were traspositioned to hopefully be out of the radiation field. All lymph nodes came back as negative on fianl path. Full pelvic radiation completed in 1998. Vagina is shortened and thin and friable. She has had menopause from the radiation (despite the repositioning of the ovaries) She has been intermittent in her commitment to estrogen (and now has T score of -1.1). She has gone back on estradiol now. She went to her PCP because she was fairly certain she had hematuria (tampon clean and urine dipped positive) PCP did urine and vaginal cultures. Urine negative and vaginal positive for Group B Beta Strep. PCP pur her on PCN. So ... Group B Beta Strep in non pregnant woman but one with irradiated vagina. Does anyone have any suggestions other than vaginal estrogen to treat the radiation fibrosis? She is basically afraid to have any sort of vaginal penetration - too short and no stretch etc. She is now 36 - divorced for a few years .. put herself through school and is an RN. Case 2. Vasomotor symptoms that are intolerable to the patient and recurring on Estratest 1.25/2.5 50yo G3P3 woman S/P TAH-USO at age 22. Menopause approximately age 47 by symptoms and FSH. Initally treated with estradiol with reasonable results. Then vasomotor symptoms returned so changed to Estratest HS (0.625 of conjugated estrogens and 1.25mg of methytestosterone) for the testoterone to decrease SHBG allowing more availability of free estrogen. She did better for about 4 months then symtpoms increased and seh was put on the "full strength" Estratest 1.25/2.5. TSH also tested 5.6 (lab normal of 0.3-5.5) with Anti-Thyroid peroxidase antibodies at 2014 (normal <60) consistent with autoimmune thyroiditis. 50mcg of levothyroxine started. Vasomotor symtoms persist. PCP says it can't be the thyroid. TSH now 3.6 (my preferred treatment range is 1-2.9) Levothyroxine increased to 75 mcg. I want to have her euthroid before changing estrogen. My thought is to bypass the liver and go with transdermal estradiol. Looking for your thoughts on work up & treatment of persistent basomotor symptoms not responding to hormones? Any other metabolic evaluation I ought to do?
-- Joanne Bulley, MD Keene, NH, USA
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