Assay for lipid peroxides in animal tissues by thiobarbituric acid reaction

CDC created U.S. Medical Eligibility Criteria for Contraceptive Use 2010 from guidance developed by the World Health Organization (WHO) and finalized the recommendations after consultation with a group of health professionals who met in Atlanta Georgia during February 2009. This guidance comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. The majority of the U.S. guidance does not differ from the WHO guidance and covers >60 characteristics or medical conditions. However some WHO recommendations were modified for use in the United States including recommendations about contraceptive use for women with venous thromboembolism valvular heart disease ovarian cancer and uterine fibroids and for postpartum and breastfeeding women. Recommendations were added to the U.S. guidance for women with rheumatoid arthritis history of bariatric surgery peripartum cardiomyopathy endometrial hyperplasia inflammatory bowel disease and solid organ transplantation. The recommendations in this document are intended to assist health-care providers when they counsel women men and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance health-care providers should always consider the individual clinical circumstances of each person seeking family planning services.

U S. Medical Eligibility Criteria for Contraceptive Use 2010: adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use 4th edition.

Background
Misoprostol (Cytotec, Searle) is a prostaglandin E1 analogue widely used for off-label indications such as induction of abortion and of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

Objectives
To determine the effects of vaginal misoprostol for third trimester cervical ripening or induction of labour.

Search methods
The Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008) and bibliographies of relevant papers. We updated this search on 15 February 2012 and added the results to the awaiting classification section.

Selection criteria
Clinical trials comparing vaginal misoprostol used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

Data collection and analysis
We developed a strategy to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

We used fixed-effect Mantel-Haenszel meta-analysis for combining dichotomous data.

If we identified substantial heterogeneity (I² greater than 50%), we used a random-effects method.

Main results
We included 121 trials. The risk of bias must be kept in mind as only 13 trials were double blind.

Compared to placebo, misoprostol was associated with reduced failure to achieve vaginal delivery within 24 hours (average relative risk (RR) 0.51, 95% confidence interval (CI) 0.37 to 0.71). Uterine hyperstimulation, without fetal heart rate (FHR) changes, was increased (RR 3.52 95% CI 1.78 to 6.99).

Compared with vaginal prostaglandin E2, intracervical prostaglandin E2 and oxytocin, vaginal misoprostol was associated with less epidural analgesia use, fewer failures to achieve vaginal delivery within 24 hours and more uterine hyperstimulation. Compared with vaginal or intracervical prostaglandin E2, oxytocin augmentation was less common with misoprostol and meconium-stained liquor more common.

Lower doses of misoprostol compared to higher doses were associated with more need for oxytocin augmentation and less uterine hyperstimulation, with and without FHR changes.

We found no information on women's views.

Authors' conclusions
Vaginal misoprostol in doses above 25 mcg four-hourly was more effective than conventional methods of labour induction, but with more uterine hyperstimulation. Lower doses (25 mcg four-hourly or less) were similar to conventional methods in effectiveness and risks. The authors request information on cases of uterine rupture known to readers. The vaginal route should not be researched further as another Cochrane review has shown that the oral route of administration is preferable to the vaginal route. Professional and governmental bodies should agree guidelines for the use of misoprostol, based on the best available evidence and local circumstances.

[Note: The 27 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

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Vaginal misoprostol for cervical ripening and induction of labour

Oxidative stress has been related increasingly to the onset and/or progression of a growing number of human diseases. However, large studies on supplementation with anti-oxidants for prevention or treatment of different pathologies have yielded contradictory and mostly negative results, as documented by numerous meta-analyses and clinical trials. Here we analyze in detail the findings of these studies and discuss major aspects that, in our opinion, are likely to be responsible for these confounding data. With the belief that a clear correlation between disease and oxidative stress is far from being proven for most pathological conditions, our argument focuses on the following points: i) choice of biomarker(s) and/or the biological system(s) for the analyses; ii) pitfalls in pre-analytical and analytical methods for assessing oxidative stress; and iii) scientific misconduct. Eventually, suggestions aiming to obtain more convergent results on this topic are provided.

Oxidative stress and human diseases: Origin, link, measurement, mechanisms, and biomarkers

Background
Heavy menstrual bleeding (HMB) is an important cause of ill health in women and it accounts for 12% of all gynaecology referrals in the UK. Heavy menstrual bleeding is clinically defined as greater than or equal to 80 mL of blood loss per menstrual cycle. However, women may complain of excessive bleeding when their blood loss is less than 80 mL. Hysterectomy is often used to treat women with this complaint but medical therapy may be a successful alternative.

The intrauterine device was originally developed as a contraceptive but the addition of progestogens to these devices resulted in a large reduction in menstrual blood loss. Case studies of two types of progesterone or progestogen-releasing systems, Progestasert and Mirena, reported reductions of up to 90% and improvements in dysmenorrhoea (pain or cramps during menstruation). Insertion, however, may be regarded as invasive by some women, which affects its acceptability as a treatment. Frequent intermenstrual bleeding and spotting is also likely during the first few months after commencing treatment.

Objectives
To determine the effectiveness, acceptability and safety of progesterone or progestogen-releasing intrauterine devices in achieving a reduction in heavy menstrual bleeding.

Search methods
All randomised controlled trials of progesterone or progestogen-releasing intrauterine devices for the treatment of heavy menstrual bleeding were obtained by electronic searches of The Cochrane Library, the specialised register of MDSG, MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (inception to December 2014) and PsycINFO (inception to January 2015). Additional searches were undertaken for grey literature and for unpublished trials in trial registers. Companies producing progestogen-releasing intrauterine devices and experts in the field were contacted for information on published and unpublished trials.

Selection criteria
Randomised controlled trials in women of reproductive age treated with progesterone or progestogen-releasing intrauterine devices versus no treatment, placebo, or other medical or surgical therapy for heavy menstrual bleeding within primary care, family planning or specialist clinic settings were eligible for inclusion. Women with postmenopausal bleeding, intermenstrual or irregular bleeding, or pathological causes of heavy menstrual bleeding were excluded.

Data collection and analysis
Potential trials were independently assessed by at least two review authors. The review authors extracted the data independently and data were pooled where appropriate. Risk ratios (RRs) were estimated from the data for dichotomous outcomes and mean differences (MD) for continuous outcomes. The primary outcomes were reduction in menstrual blood loss and satisfaction; in addition, rate of adverse effects, changes in quality of life, failure of treatment and withdrawal from treatment were also assessed.

Main results
We included 21 RCTs (2082 women). The included trials mostly assessed the levonorgestrel-releasing intrauterine device (LNG IUS) (no conclusions could be reached from one small study assessing Progestasert which was discontinued in 2001) and so conclusions are based only on LNG IUS. Comparisons were made with placebo, oral medical treatment, endometrial destruction techniques and hysterectomy. Ratings for the overall quality of the evidence for each comparison ranged from very low to high. Limitations in the evidence included inadequate reporting of study methods and inconsistency.

Seven studies compared the LNG IUS with oral medical therapy: either norethisterone acetate (NET) administered over most of the menstrual cycle, medroxyprogesterone acetate (MPA) (administered for 10 days), the oral contraceptive pill, mefenamic acid or usual medical treatment where participants could choose the oral treatment that was most suitable. The LNG IUS was more effective at reducing HMB as measured by the alkaline haematin method (MD 66.91 mL, 95% CI 42.61 to 91.20; two studies, 170 women; I2 = 81%, low quality evidence) or by Pictorial Bleeding Assessment Chart (PBAC) scores (MD 55.05, 95% CI 27.83 to 82.28; three studies, 335 women; I2 = 79%, low quality evidence), improving quality of life and a greater number of women continued with their treatment at two years when compared with oral treatment. Although substantial heterogeneity was identified for the bleeding outcomes, the direction of effect consistently favoured the LNG IUS. There was insufficient evidence to reach conclusions on satisfaction. Minor adverse effects (such as pelvic pain, breast tenderness and ovarian cysts) were more common with the LNG IUS.

Ten studies compared the LNG IUS with endometrial destruction techniques: three with transcervical resection, one with rollerball ablation and six with thermal balloon ablation. Evidence was inconsistent and very low quality with respect to reduction in bleeding outcomes and satisfaction was comparable between treatments (low and moderate quality evidence). Improvements in quality of life were experienced with both types of treatment. Minor adverse events were more common with the LNG IUS overall, but it appeared more cost effective compared to thermal ablation within a two-year time frame in one study.

Three studies compared the LNG IUS with hysterectomy. The LNG IUS was not as successful at reducing HMB as hysterectomy (high quality evidence). The women in these studies reported improved quality of life, regardless of treatment. In spite of the high rate of surgical treatment in those having LNG IUS within 10 years, the LNG IUS was more cost effective than hysterectomy.

Authors' conclusions
The levonorgestrel-releasing intrauterine device (LNG IUS) is more effective than oral medication as a treatment for heavy menstrual bleeding (HMB). It is associated with a greater reduction in HMB, improved quality of life and appears to be more acceptable long term but is associated with more minor adverse effects than oral therapy.
When compared to endometrial ablation, it is not clear whether the LNG IUS offers any benefits with regard to reduced HMB and satisfaction rates and quality of life measures were similar. Some minor adverse effects were more common with the LNG IUS but it appeared to be more cost effective than endometrial ablation techniques.

The LNG IUS was less effective than hysterectomy in reducing HMB. Both treatments improved quality of life but the LNG IUS appeared more cost effective than hysterectomy for up to 10 years after treatment.

Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding

Genital tuberculosis in Indian infertility patients.

Aim: Menopause is a pro-atherogenic state with a sharp rise in the incidence of coronary artery disease. This pilot study was designed as an equivalence randomized clinical trial to explore the potential of LycoRed (containing 2000 µg lycopene) as an alternative to hormone replacement therapy (HRT) for the prevention of coronary artery disease in postmenopausal women. Methods: Forty-one healthy postmenopausal women were randomly allocated to receive either continuous combined HRT (n = 21) or LycoRed (n = 20) for six months. Serum lipid profile, marker of lipid peroxidation (malondialdehyde), and the level of endogenous antioxidant (glutathione) were measured at the baseline, and 3 and 6 months after the intervention in both groups. Results: At 6 months, HRT resulted in a significant decrease in total cholesterol (TC) level by 23.5%, lowdensity lipoproteins (LDL) by 19.6%, and an increase in high-density lipoproteins (HDL) by 38.9%. The LycoRed group showed similar changes in TC (−24.2%), LDL (−14.9%) and HDL (+26.1%). Triglyceride levels showed a smaller though significant increase at 6 months, but not at 3 months, in both groups. There was no significant change in the very LDL (VLDL) level in either group. Malondialdehyde levels decreased significantly by 16.3% and 13.3%, whereas glutathione levels increased significantly by 5.9% and 12.5% in HRT and LycoRed groups, respectively. Conclusion: Both HRT and LycoRed had a favorable effect on serum lipids and oxidative stress markers which were comparable. LycoRed can be used as an alternative to HRT to reduce the risk of atherosclerosis in postmenopausal women.

LycoRed as an alternative to hormone replacement therapy in lowering serum lipids and oxidative stress markers: a randomized controlled clinical trial.

Metformin therapy in women with polycystic ovary syndrome.

Aim: To compare the efficacy of glyceryl trinitrate (GTN), dinoprostone and misoprostol for preinduction cervical ripening in primigravida at term.



Methods: Sixty-five term primigravida, each with an unfavorable cervix (Bishop score ≤5), were randomized to receive GTN (0.5 mg perivaginally, n = 21), dinoprostone gel (0.5 mg intracervically, n = 21) and misoprostol (50 µg perivaginally, n = 23) for a maximum of two doses, 6 h apart. Statistical analysis included paired t-tests to compare pre- and post-treatment Bishop scores, one-way analysis of variance (anova) tests to compare quantitative variables and chi-squared tests to compare the proportion of subjects achieving favorable Bishop scores.



Results: Baseline Bishop scores were similar in the GTN (3.4 ± 0.9), dinoprostone (3.4 ± 1.0) and misoprostol groups (3.2 ± 1.2). The final outcome was favorable (Bishop score >6) in a greater proportion of subjects in the misoprostol (n = 18, 81.8%) and dinoprostone (n = 14, 66.7%) groups compared with the GTN group (n = 11, 55%). In subjects with a severely unfavorable cervix (Bishop score ≤3), treatment with misoprostol led to a favorable response in 61.6% of patients compared with 45.6% in the misoprostol group and 33.3% in the GTN group. A significant improvement was noted in the Bishop score of all three groups (P < 0.001) but the increase in Bishop score was greater in misoprostol (3.5 ± 2.1) and dinoprostone groups (2.8 ± 1.5), compared with the GTN group (2.0 ± 1.0, anovaF = 4.8, P = 0.01). Hyperstimulation and tachysystole were observed only in the misoprostol  (9%  and  4.3%)  and  dinoprostone  groups  (4.7%  and  16.2%).  The  most  common  adverse  effect  in  the GTN group was headache, which was observed in 47.6% of this group's subjects.



Conclusion: The findings of the present study suggest that GTN is safer, but less efficacious, compared with prostaglandins for preinduction cervical ripening at term.

Evaluation of glyceryl trinitrate, misoprostol, and prostaglandin E2 gel for preinduction cervical ripening in term pregnancy.

Roberts uterus or asymmetric septate uterus is an uncommon uterine mullerian anomaly first reported by Robert in 1970. It has two uterine cavities with one being blind causing menstrual retention. Till date only 17 such cases have been reported in literature. A unique congenital mullerian anomaly; asymmetric septate uterus with noncommunicating right sided hemicavity and haematometra a normal extrauterine morphology with right ovarian maldescent and stage III endometriosis was diagnosed on laparotomy. (excerpt)

Renu Misra

Papers

Genital tuberculosis in Indian infertility patients.

LycoRed as an alternative to hormone replacement therapy in lowering serum lipids and oxidative stress markers: a randomized controlled clinical trial.

Metformin therapy in women with polycystic ovary syndrome.

Evaluation of glyceryl trinitrate, misoprostol, and prostaglandin E2 gel for preinduction cervical ripening in term pregnancy.

A unique congenital mullerian anomaly: Robert's uterus.