Showing papers in "Journal of Reproductive Medicine in 2001"

Natural history of twin-twin transfusion syndrome.

Abstract: OBJECTIVE To determine the natural history of pregnancies with twin-twin transfusion syndrome (TTTS). STUDY DESIGN All cases of TTTS at our institution since 1991 and in a MED-LINE search since 1966 were retrospectively reviewed. The prenatal diagnosis of TTTS required the presence of monochorionic/diamniotic placentation (absence of twin-peak sign, thin membrane, single placenta, same sex) and of polyhydramnios (largest pocket > 8 cm) in one sac and oligohydramnios (largest pocket < 2 cm or stuck twin) in the other. Only cases diagnosed at < or = 28 weeks were included. Upon diagnosis, all patients were counseled as to the availability, risks and benefits of serial amniocentesis, laser therapy, septostomy, umbilical cord ligation, and other medical and surgical interventions. RESULTS Of 29 pregnancies identified at our institution with the above strict criteria for TTTS, 5 (17%) declined in utero therapy and were managed expectantly. The mean gestational age at presentation was 19.2 weeks (range, 16-28) and at delivery, 33.8 weeks (range, 22-41). Four (40%) of the twins survived past the neonatal period, and of the three with follow-up, all are free of neurologic sequelae despite the death in utero of their cotwin. From the literature, 136 fetuses with TTTS as defined above and managed expectantly were identified; 37 (27%) survived; 75% (9/12) of survivors with follow-up are neurologically normal. The most recent four studies have reported survival of untreated cases of 50% (17/34) when diagnosed at < or = 26 weeks and of 63% (20/32) when diagnosed at < or = 28 weeks. CONCLUSION The perinatal survival of TTTS pregnancies managed without in utero procedures is approximately 30% overall and 63% in the four most recent series when diagnosed at < or = 28 weeks. The success of in utero therapeutic intervention should be assessed by randomized studies or at least compared to that in similar cases managed without such intervention.

Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature.

Abstract: Objective To evaluate the effectiveness of electromyographic biofeedback of pelvic floor musculature in the management of patients with moderate to severe vulvar vestibulitis syndrome. Study design Twenty-nine patients with moderate to severe vulvar vestibulitis syndrome were included in this study. Each patient was given a computerized electromyographic assessment of pelvic floor muscles. She was then provided with a portable electromyographic home trainer biofeedback device, and specific instructions were given to perform biofeedback-assisted pelvic floor muscle rehabilitation exercises. The patients received monthly evaluations of the pelvic floor muscles to ensure and motivate compliance and to monitor improvement and symptom changes. Patients were evaluated on a monthly basis for vestibulodynia and dyspareunia. Results Fifteen of the 29 treated patients (51.7%) demonstrated markedly decreased introital tenderness, and 14 of them (93.3%) were able to resume sexual activity without discomfort. Nine patients (31.0%) demonstrated a significant decrease in introital tenderness and pain, and six of the nine (66.7%) resumed sexual activity. Thus, 20 of the 29 women (69%) became sexually active. Following completion of treatment, 24 (88.9%) reported negligible or mild pain. Five of the 29 did not show any significant improvement, and none of them were able to resume sexual activity. Within six months of the start of therapy, 90% ultimately resuming sexual activity had done so. Conclusion Electromyographic biofeedback of pelvic floor musculature is an effective approach to vulvar vestibulitis.

Does Prayer Influence the Success of in Vitro Fertilization-Embryo Transfer? Report of a Masked, Randomized Trial

Abstract: OBJECTIVE: To assess the potential effect of intercessory prayer (IP) on pregnancy rates in women being treated with in vitro fertilization-embryo transfer (IVF-ET). STUDY DESIGN: Prospective, double-blind, randomized clinical trial in which patients and providers were not informed about the intervention. Statisticians and investigators were masked until all the data had been collected and clinical outcomes were known. The setting was an IVF-ET program at Cha Hospital, Seoul, Korea. IP was carried out by prayer groups in the United States, Canada and Australia. The investigators were at a tertiary medical center in the United States. The patients were 219 women aged 26-46 years who were consecutively treated with IVF-ET over a four-month period. Randomization was performed after stratification of variables in two groups: distant IP vs. no IP. The clinical pregnancy rates in the two groups were the main outcome measure. RESULTS: After clinical pregnancies were known, the data were unmasked to assess the effects of IP after assessment of multiple comparisons in a log-linear model. The IP group had a higher pregnancy rate as compared to the no-IP rate (50% vs. 26%, P=.0013). The IP group showed a higher implantation rate (16.3% vs. 8%, P=.0005). Observed effects were independent of clinical or laboratory or providers and clinical variables. Conclusion: A statisticalluy significant difference vas observed for the effect of IP on the outcome of IVF-ET, though the data should be interpreted as preliminary.

Gynecologists' patterns of prescribing pessaries.

Abstract: OBJECTIVE: To determine how gynecologists in the United States prescribe pessaries. STUDY DESIGN: A 34-question (long) survey was sent to 2,000 gynecologists. Those who did not respond were then sent a five-question (short) survey. RESULTS: Nine hundred forty-seven (47.3%) long and short questionnaires were returned. Eighty-six percent of gynecologists prescribe pessaries. Most received minimal or no training in pessaries in their residencies. The most common pessaries used were the ring and doughnut. Uterine prolapse was treated most often with the Gellhorn and doughnut pessaries. The cube and Gellhorn pessaries were thought to be the most effective for vaginal vault prolapse. The Gehrung and ring pessaries were thought to be most effective for correction of cystocele. However, the ring pessary was considered the easiest to use. Follow-up visits were most often performed at one week, one month and then every three months. Estrogen was used in most cases. CONCLUSION: Most gynecologists prescribe pessaries. The ring pessary is used most often and is deemed the easiest to use. Pessaries are thought to work for all pelvic organ prolapse defects but are thought to be less effective for posterior defects. Follow-up of patients differs from manufacturers' recommendations.

Soy isoflavone supplementation in postmenopausal women. Effects on plasma lipids antioxidant enzyme activities and bone density.

Abstract: The aim was to investigate isoflavone supplementation on plasma lipids erythrocyte antioxidant enzyme activities and bone mineral density in postmenopausal women. 37 postmenopausal women were given 150 mg/d of isoflavone supplements twice daily for 6 months. Blood was sampled before and after supplementation at 3 and 6 months. There were no significant differences in plasma total cholesterol high-density lipoprotein cholesterol low-density lipoprotein cholesterol triglyceride concentrations or erythrocyte antioxidant enzyme activities after 3 and 6 months of supplementation when compared with the baseline. No significant changes were noted in calcaneus bone mineral density after supplementing isoflavones for 6 months. The antioxidant effect of isoflavones in normal postmenopausal women is not obvious and supplementation with isoflavone alone may not have a hypocholesterolemic effect. Since the duration of this study was too short with respect to bone density longer studies are needed to clarify the bone-sparing effect of isoflavone supplementation. (authors)

Relationship of abnormal vaginal flora, proinflammatory cytokines and idiopathic infertility in women undergoing IVF

Abstract: OBJECTIVE: To investigate the prevalence of bacterial vaginosis (BV) and abnormal bacterial vaginal flora in an infertile population and correlate with cervical cytokine production and in vitro fertilization (IVF) outcome. STUDY DESIGN: In a blinded study, 331 asymptomatic IVF patients were evaluated for BV, abnormal vaginal flora and cervical cytokine production (interleukin 1β [IL-1β] and IL-8) on the day of oocyte retrieval. All patients received tetracycline prophylaxis at the time of oocyte retrieval. RESULTS: BV was identified in 4.2% (14/331) ofthe patients. Patients with idiopathic infertility were more likely to have BV than were women with other causes of infertility (P =.02 vs. male factor, P =.03 vs. tubal factor and P <.01 vs. endometriosis-associated infertility). Patients with abnormal vaginal flora had higher cervical IL-1β and IL-8 cytokine levels as compared to patients with normal vaginal flora. IL-1β and IL-8 levels in the study subjects correlated highly. No differences were detected in IVF outcome parameters based on the vaginal flora determined at the time of retrieval. CONCLUSION: Abnormal vaginal flora, including that causing BV, is associated with elevated cervical levels of IL-1β and IL-8. The induction of proinflammatory cytokines by an altered vaginal ecosystem may be a previously unrecognized cause of idiopathic infertility.

Advances in the management of epithelial ovarian cancer.

Abstract: More than 23,400 new cases of ovarian cancer and 13,900 deaths are expected in the United States this year. Epithelial ovarian cancer is the most common histologic type of ovarian malignancy. Although there have been advances in the chemotherapeutic treatment of ovarian cancer, the five year survival of women with advanced-stage disease is 25-30%. Because the disease is typically asymptomatic until the disease has metastasized and because effective screening strategies are not unavailable, 70-75% of women present with advanced-stage disease. Of ovarian cancer cases, 90-95% are sporadic and 5-10% associated with germ-line mutations, including BRCA1 and BRCA2. Known risk factors for ovarian cancer include nulliparity and a strong family history of ovarian cancer. The use of oral contraceptives is known to decrease the risk of ovarian cancer: five years of use will decrease the risk by 50%. The staging of ovarian cancer (according to the International Federation of Obstetrics and Gynecology) requires surgical exploration. Determining the extent of disease is essential to appropriate management. Survival in patients with metastatic disease is improved in those who undergo optimal primary cytoreductive surgery. Adjuvant chemotherapy is recommended in patients with high-risk, early-stage disease and all patients with advanced-stage disease. Standard chemotherapy is a combination of paclitaxel and carboplatin. Selected patients with recurrent disease can undergo secondary cytoreductive surgery. Second-line chemotherapy for patients who initially respond to paclitaxel and carboplatin and who have a prolonged disease progression-free intervals (longer than 12 months) can be re-treated with either drug or both. Those whose responses to initial therapy were less successful can be treated with other chemotherapeutic agents--e.g., liposomal doxorubicin, topotecan, etoposide, gemcitabine or taxotere.

Influenza vaccination during pregnancy. Patients' and physicians' attitudes.

Abstract: OBJECTIVE To identify potentially remediable attitudinal factors among women and their physicians that may present barriers to influenza vaccination during pregnancy. STUDY DESIGN We conducted a prospective survey study administered concurrently during influenza season (January-March 2000) to postpartum women in an urban, high-volume medical center and to practicing obstetricians in the metropolitan Los Angeles area. Analyses focused on individual questions' relation to the outcomes of: (1) patients' receipt of influenza vaccine during the recently completed pregnancy, and (2) physicians' discussion of influenza vaccine with their pregnant patients. RESULTS Surveys were completed by 242 postpartum women and 113 physicians. Among the women, 22% had discussed influenza vaccine with their physicians during pregnancy, with only 8% of respondents having been vaccinated. Significantly more physicians stated that they discussed vaccination with their patients than did women (74% vs. 22%; P < .001). Physicians were more likely to recommend vaccine if they were aware of current Centers for Disease Prevention and Control guidelines (RR = 2.6, 1.1-5.9), gave vaccinations in their offices (RR = 1.2, 1.01-1.4) and had been vaccinated against influenza themselves (RR = 1.9, 1.3-2.8). CONCLUSION Influenza vaccination during pregnancy occurred infrequently in this study cohort, and a significant discrepancy was seen between patients' and physicians' impressions of whether its use or recommendation had been discussed. Gaps existed in both groups' understanding of potential benefits of influenza vaccine for both pregnant women and their newborns. The survey results suggest potential strategies for targeting improved educational programs for physicians and patients to improve influenza vaccination rates for pregnant women.

Prevalence of metronidazole-resistant Trichomonas vaginalis in a gynecology clinic.

Abstract: Objective To determine the prevalence of in vitro resistance to metronidazole among unselected isolates of Trichomonas vaginalis and correlate in vitro findings with response to metronidazole therapy. Study design Vaginal fluid from women attending a gynecology clinic at an urban hospital was cultured, isolates were tested for in vitro resistance to metronidazole, and these results were correlated with therapeutic outcome. Results Among 911 women, T vaginalis was detected by culture in 82 (9.0%). Of the 82 isolates, 2 (2.4%; 95% CI, 0.3-8.5%) had low-level in vitro resistance (minimum lethal concentration, 50 micrograms/mL). Women with positive wet mount examinations were treated with metronidazole, 2 g, once and asked to return in one week. Of the 42 infected women agreeing to return for a repeat examination and culture, 26 (61.9%) did, and all (including one woman with a resistant isolate) were cured. Conclusion Isolates of T vaginalis resistant to metronidazole occur widely throughout the United States. Although the in vitro susceptibility of T vaginalis to metronidazole has been very poorly studied, our study is consistent with a decade-old prevalence estimate of in vitro resistance (5%), and suggests that high-level resistance is uncommon. This study confirmed, in the absence of reinfection, the continuing clinical effectiveness of single-dose metronidazole for the large majority of trichomoniasis cases.

Psychosexual aspects of vulvar vestibulitis.

Abstract: OBJECTIVE: To explore the psychological, interpersonal and sexual correlates of vulvar vestibulitis via qualitative and quantitative analysis. STUDY DESIGN: Sixty-nine women diagnosed with vestibulitis were recruited from a vulvar/vaginal disease clinic to complete a comprehensive quantitative and qualitative questionnaire designed to assess general health concerns, mental health, sexual functioning and interpersonal relationships. RESULTS: The majority of participants reported drastic changes in sexuality associated with the onset of vestibulitis. Upon developing vestibulitis, 88% reported decreased interest in sexual activity, 87% indicated that they were less willing to participate in sexual activity, and 94% maintained that they were less able to participate in sexual activity. High levels of frustration and symptoms of depression also were frequently reported. CONCLUSION: Vulvar vestibulitis is associated with significant changes in sexuality, intimate relationships and psychological well-being. When treating women with vestibulitis, medical professionals should consider the psychological and sexual aspects of the disease in addition to physical concerns.

Effect of acupressure on nausea and vomiting during pregnancy. A randomized, placebo-controlled, pilot study.

Abstract: OBJECTIVE: To compare the antiemetic effect of acupressure at the Neiguan point (P6) in a group of healthy women with normal pregnancy and nausea and vomiting during pregnancy (NVP) with a similar group receiving acupressure at a placebo point and another, similar group not receiving any treatment. STUDY DESIGN: A randomized, placebo-controlled, pilot study involving 60 women. RESULTS: It is possible to reduce NVP significantly with acupressure at P6 as compared to acupressure at a placebo point or no treatment at all in healthy women with normal pregnancies. Relief from nausea appeared one day after starting treatment in both the P6 and placebo groups but lasted for only six days in the placebo group. The P6 group, however, experienced significantly less nausea after 14 days as compared to the other two groups. CONCLUSION: This study involved 60 healthy women with normal pregnancy and suffering from NVP. According to the results, in healthy women with normal pregnancy it is possible to reduce NVP significantly at P6 as compared to acupressure at a placebo point and to no treatment.

Pyometra. What is its clinical significance

Abstract: OBJECTIVE: To evaluate the clinical outcomes of pyometra. STUDY DESIGN: Retrospective study conducted between 1993 and 1999 in two regional hospitals. RESULTS: Pyometra represented 0.038% of gynecologic admissions. Of the 27 women with pyometra 6 (22.2%) cases were associated with malignancy 1 (3.7%) was associated with genital tract abnormality and 20 (74.1%) were idiopathic. Patients with idiopathic pyometra tended to be older and had a higher incidence of concurrent medical conditions. Five (18.5) women experienced spontaneous perforation of pyometra. A preoperative diagnosis was correctly made in 17 of 22 (77.3%) patients without spontaneous perforation. Most women were treated with dilatation of the cervix and drainage. Nine women (33.3%) had persistent or recurrent pyometra; three of them were asypmtomatic. CONCLUSION: Pyometra is an uncommon condition but the incidence of associated malignancy is considerable and the risk of spontaneous perforation is higher than previously thought. Dilation and drainage is the treatment of choice and regular monitoring after initial treatment is warranted to detect persistent and recurrent disease. (authors)

Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types.

Abstract: OBJECTIVE To determine the risk factors for third-degree perineal tears during vaginal delivery and to investigate the relation between different types of episiotomy and the occurrence of such tears. STUDY DESIGN This retrospective multicenter study consisted of an analysis of data from the delivery databases of the University Hospital of Vienna and Semmelweis Frauenklinic Wien between February and July 1999. The study was restricted to a sample that included all women with uncomplicated pregnancy as well as uncomplicated first and second stages of labor, gestational age > 37 weeks and a pregnancy with cephalic presentation. Women with multiple gestations, noncephalic presentation, cesarean deliveries, shoulder dystocia and gestational age < or = 37 weeks were excluded from the study. RESULTS Among the 1,118 births, 37 women (3.3%) experienced third-degree perineal tears. The use of episiotomy per se and the type of episiotomy (midline) as well as forceps delivery, primiparity, large infant head diameter, prolonged second stage of labor and use of oxytocin were identified as risk factors for third-degree perineal tears during vaginal delivery. When analyzing different types of episiotomy, there was approximately a sixfold-higher risk of third-degree perineal tears in women undergoing midline episiotomy as compared to mediolateral episiotomy. A stepwise logistic regression analysis revealed that episiotomy, prolonged second stage of labor and large infant head diameter remained independent risk factors for third-degree perineal tears. CONCLUSION We found several risk factors for third-degree perineal tears. The use of midline episiotomy was associated especially with an increased risk of severe anal sphincter tears. To prevent women from long-term sequelae due to third-degree perineal tears, avoidable risk factors should be minimized whenever possible.

Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications.

Abstract: Objective To prospectively evaluate the prevalence, presumed etiologies and clinical implications of persistent postpartum urinary retention in modern obstetric practice Study design The study population comprised 8,402 consecutive, unselected parturients delivered in a university-affiliated maternity hospital over a one-year period If a woman was unable to void spontaneously until the third postpartum day despite intermittent use of a Foley catheter, a diagnosis of persistent postpartum urinary retention was established Patients were treated by insertion of a Foley catheter for up to two weeks and subsequently by a suprapubic catheter Obstetric data were collected from the hospital records Results Four patients (005% of the study population), aged 29-37 years, developed persistent postpartum urinary retention Risk factors included vaginal delivery after cesarean section, prolonged second stage of labor, epidural analgesia, and delayed diagnosis and intervention Urodynamic evaluation, performed on two patients one month after removal of the suprapubic catheter, revealed genuine stress incontinence in one and detrusor instability in another None had had any lower urinary tract symptoms before pregnancy and delivery Conclusion Persistent postpartum urinary retention in contemporary obstetric practice is rare but may be associated with long-term bladder dysfunction Early diagnosis and intervention are required to prevent irreversible bladder damage

Amniotic fluid index in the uncomplicated term pregnancy: Prediction of outcome

Abstract: OBJECTIVE: To establish whether an association between oligohydramnios and pregnancy outcome is present in the uncomplicated term pregnancy STUDY DESIGN: Pregnancies with a singleton fetus in cephalic presentation at term (≥ 37 weeks), a reactive non-stress test and an antepartum amniotic fluid index performed within four days of delivery between January 1994 and September 1998 were identified Excluded were those with any maternal or fetal complication or unavailable outcome information The primary outcome measure was rate of operative vaginal or abdominal delivery for a nonreassuring fetal heart rate tracing Statistical analysis included Fisher's exact test and one-way analysis of variance, with a two-tailed P 5 cm vs ≤5 cm (39 [21%] vs 5 [11%], P >05) In addition, there were no differences between the two groups in rates of neonatal intensive care unit admissions or five-minute Apgar scores < 7 Patients with a normal amniotic fluid index had a significantly lower labor induction rate (96 [51%] vs 42 [98%], P <001) and higher rate of meconium-stained amniotic fluid (65 [35%] vs 7 [16%], P =01) than those with a low amniotic fluid index CONCLUSION: In the uncomplicated pregnancy at term, an amniotic fluid index ≤ 5 cm increases the incidence of labor induction but does not appear to affect the rate of operative delivery for abnormal fetal heart rate tracings

Vitamin B12 deficiency, infertility and recurrent fetal loss.

Abstract: The aim was to examine the relationship of infertility to recurrent fetal loss in patients who were vitamin B12 deficient. The obstetric histories of 14 patients presenting with 15 episodes of vitamin B12 deficiency were analyzed. Infertility (2-8 years) had been present in 4 episodes and recurrent fetal loss was a feature in 11. In 6 episodes periods of recurrent fetal loss were followed by periods of infertility >1 year. Hypercoagulability due to raised homocysteine levels may lead to fetal loss when vitamin B12 deficiency first develops. A more prolonged deficiency results in infertility by causing changes in ovulation or development of the ovum or changes leading to defective implantation. (authors)

Preterm delivery and the severity of violence during pregnancy

Abstract: OBJECTIVE: To determine the severity and consequences of physical violence during pregnancy among participants in a health department prenatal care coordination program. STUDY DESIGN: The prospective cohort study included all program participants from 1994 to 1996. Care coordinators screened participants for physical violence during pregnancy using a validated, systematic assessment protocol three times during prenatal care. The protocol was linked with prenatal records, delivery records and infant records to document complications and infant outcomes. Multiple logistic regression was used to assess the relationship between severe physical violence during pregnancy and pregnancy outcome while controlling for confounding factors. RESULTS: Among the 550 participants, 13.5% reported violence during pregnancy; it included 6.7% severe violence (hitting, kicking, injury with a weapon and abdominal injury) and 6.7% moderate violence (threats, slapping, shoving and sexual abuse). Severe physical prenatal violence was significantly associated with spontaneous preterm labor, preterm delivery, very preterm delivery, very low birth weight, preterm/low birth weight, mean birth weight, mean newborn hospital charges, five-minute Apgar <7, neonatal intensive care unit admission, and fetal or neonatal death. Body site injured, timing of violence and number of violent incidents were significant factors associated with violence during pregnancy and preterm delivery. CONCLUSION: Because severe physical violence during pregnancy was a significant problem in this population, intervention programs are needed to reduce prenatal violence and its consequences.

Psychological consequences of surgical menopause.

Abstract: More than 250,000 women have a bilateral oophorectomy every year. With surgical menopause, the onset of menopausal symptoms is abrupt and often dramatic. Oophorectomy offers relief from physical conditions for many women; however, those with preexisting psychological and some physical problems tend to experience postsurgical exacerbation of those problems. Loss of estrogenic and androgenic underpinnings may destabilize women with unstable psychiatric axes. Surgically menopausal women may also experience a decline in sexual interest and activity. The relation of surgical menopause to physiologic and sexual well-being is described in this article. The link between hormonal levels and psychological well-being has been well documented. Depression seems to be increased at times of changing hormone levels in women, possibly a result of the effect of estrogen levels on serotonergic activity and its impact on other neurotransmitters. In addition, a sex-specific association with specific psychological disorders has been described in the literature and will be reviewed in this article. The potential benefits of estrogen or estrogen/androgen therapy on libido and mood are discussed, as are findings that estrogen-androgen therapy correlated with less anxiety and hostility and with increased positive feelings when compared with estrogen-only treatment.

Leiomyosarcoma after uterine artery embolization. A case report.

Abstract: BACKGROUND: Hysterectomy is the most common treatment for relieving symptoms attributable to uterine leiomyomas; however, alternatives to hysterectomy are becoming increasingly available. Uterine artery embolization is being used more frequently in this clinical setting. CASE: A leiomyosarcoma was diagnosed incidentally in a 51-year-old, nulliparous woman who underwent uterine artery embolization for symptomatic leiomyomata and subsequent total abdominal hysterectomy/bilateral salpingo-oophorectomy due to unsatisfactory results of the embolization procedure. CONCLUSION: While the occurrence of preoperatively undiagnosed uterine leiomyosarcomas among patients undergoing hysterectomies has been reported, there are no reports of unsuspected leiomyosarcomas after uterine artery embolization. Criteria for selection of patients for the procedure should consider the possibility of leiomyosarcoma. With the increasing popularity of uterine artery embolization, cases like this are likely to be encountered in the future.

Bone mineral density in young, hypothalamic oligoamenorrheic women treated with oral contraceptives.

Abstract: OBJECTIVE: To evaluate whether decreasing doses of ethinyl estradiol affect bone loss related to hypothalamic amenorrhea. STUDY DESIGN: Sixty-four women with hypothalamic oligoamenorrhea were allocated to two therapy groups: group A (n = 24) received an OC containing 0.030 mg of ethinyl estradiol (EE) and 0.15 mg of desogestrel. Group B (n = 22) received an OC containing 0.020 mg of EE and 0.15 mg of desogestrel. Eighteen women who did not wish to use hormonal therapy constituted the control group (C). Calcium, phosphate and osteocalcin were measured basally and at 6 and 12 months of follow-up. Bone mineral density at the lumbar spine was determined before initiation of the study and at 12 months by dual energy X-ray absorptiometry. RESULTS: Serum calcium, phosphate and osteocalcin were significantly reduced by both active treatment regimens, whereas no differences were observed in the control group. Bone mineral density at 12 months showed an increase in both therapy groups (A, 2.4%; B, 2.5%), while group C showed a significant decrease (1.2%, P <.05). CONCLUSION: Both doses of EE were equally effective in preventing bone loss related to hypoestrogenism in hypothalamic oligoamenorrheic subjects.

Increased nitric oxide in peritoneal fluid from women with idiopathic infertility and endometriosis.

Abstract: OBJECTIVE To verify whether nitric oxide in peritoneal fluid is associated with endometriosis and infertility. STUDY DESIGN Twenty-five women with idiopathic infertility and 38 with endometriosis were recruited, and 18 cases of uterine myomata and 2 cases of ovarian cyst served as controls. Peritoneal fluid samples were aspirated from the pouch of Douglas during laparoscopy or laparotomy. Metabolites of nitric oxide (nitrite and nitrate) in peritoneal fluid were determined by a method using nitrate reductase and the Griess reaction. RESULTS Peritoneal concentrations of nitrate/nitrite in both infertile women (42.02 +/- 12.98 mmol/L) and patients with endometriosis (41.75 +/- 16.42 mmol/L) were significantly higher than that in controls (33.96 +/- 13.07, P .5). Peritoneal levels of nitrate/nitrite were comparable among patients with endometriosis at different stages (P > .5). Patients with endometriosis had more peritoneal fluid than controls and idiopathic infertile women, while controls and idiopathic infertile women had comparable amounts of peritoneal fluid. CONCLUSION An increased peritoneal level of nitric oxide is a common alteration in endometriosis, endometriosis-associated infertility and idiopathic infertility and may be associated with the pathogenesis of these diseases.

Testosterone deficiency in women.

Abstract: Testosterone (T) is an important component of female sexuality, enhancing interest in initiating sexual activity and response to sexual stimulation. Testosterone is also associated with greater well-being and with reduced anxiety and depression. Clinical and biochemical definitions of T deficiency have not been established; hence, the prevalence of this condition is not known. However, surgically menopausal women are among the populations most likely to experience T deficiency, a syndrome characterized by blunted or diminished motivation; persistent fatigue; decreased sense of personal well-being; sufficient plasma estrogen levels; and low circulating bioavailable T (either a low total T/sex hormone binding globulin (SHBG) ratio or free T in the lower one-third of the female reproductive range); and low libido. Exogenous estrogen, particularly when administered orally, increases SHBG, which, in turn, reduces free T and estradiol (E2). After oophorectomy, levels of T and its precursor, androstenedione, decline by approximately 50%. T replacement continues to be evaluated as an adjunct to estrogen replacement therapy, particularly for women with androgen deficiency symptoms, surgically menopausal women and women with premature ovarian failure. In the United States, oral methyltestosterone is the common product currently approved for androgen replacement in women. The best product specifically designed for women has yet to be determined, as standardized, long-term, randomized, control clinical studies are lacking and product refinement continues.

Treatment of vulvar vestibulitis with submucous infiltrations of methylprednisolone and lidocaine. An alternative approach.

Abstract: OBJECTIVE: To assess the efficacy of submucous infiltrations of methylprednisolone and lidocaine into the vulvar vestibule for the treatment of vulvar vestibulitis. STUDY DESIGN: Twenty-two patients were referred for vulvar vestibulitis. Methylprednisolone and lidocaine were injected into the vulvar vestibule once a week for three weeks at decreasing doses (1, 0.5, 0.3 mL). Follow-up was performed monthly for three months, then at six and nine months. Fourteen women have had 12 months and 5 women, 24 months of follow-up. RESULTS: Fifteen women (68%) ) responded favorably to the treatment, seven (32%) with absence of symptoms and eight (36%) with a marked improvement. Seven patients (32%) failed to respond in spite of a fourth dose (0.3 mL) given after 30 days. No relapse was observed at nine months' follow-up, while a further 0.5 mL infiltration followed by quick remission of symptoms was needed after one year in five patients. Five patients completed the 24 months' follow-up, with no need for further treatment. CONCLUSION: Submucous infiltration allows methylprednisolone to be deposited in the submucosa, the site of the inflammatory reaction, while the depot formulation allows gradual and prolonged release of the drug. Seven patients (32%) failed to respond, suggesting either that they had a kind of vulvar vestibulitis syndrome where inflammation is less remarkable or failure of the infiltrated drug to become adequately diffused.

Treatment of cervical pregnancy with cerclage, curettage and balloon tamponade. A report of three cases.

Abstract: BACKGROUND: Cervical pregnancy is a rare form of ectopic pregnancy, historically requiring hysterectomy to control life-threatening hemorrhage. However, with early diagnosis, conservative procedures can preserve the uterus and fertility. CASES: Three cases of cervical pregnancy were treated successfully with curettage. Two cases utilizing precurettage and postcurettage hemostatic techniques were treated with curettage alone. A third case, not employing precurettage hemostatic maneuvers, required uterine artery embolization to control bleeding and avoid hysterectomy. CONCLUSION: Curettage alone, when preceded by cervical infiltration with a vasoconstricting agent, placement of a cerclage suture high on the cervix and followed by cervical canal tamponade with a Foley catheter balloon, can successfully treat early cervical pregnancy.

Direct-to-vial experience with AutoCyte PREP in a small New England regional cytology practice.

Abstract: OBJECTIVE To evaluate and assess the efficiency and efficacy of the AutoCyte PREP thin-layer Pap test method (TriPath Imaging, Inc., Burlington, North Carolina) in a privately owned cytology laboratory. STUDY DESIGN Data from 35,496 conventional Pap smear preparations performed in 1999 were compared to 6,357 conventional Pap smears and 15,534 AutoCyte PREP cases that were collected, prepared and processed from January 1 to July 31, 2000. RESULTS The AutoCyte PREP demonstrated a statistically significant increased detection of low grade squamous intraepithelial lesions (LSIL) (47%) (P = .0011) and high grade squamous intraepithelial lesions (HSIL) (116%) (P = .0002) when compared to conventional Pap smears processed during the same time period. When compared to the conventional Pap smears from 1999, the LSIL lesions increased by 57% (P < .00001), and the HSIL lesions increased by 55% (P = .0002). Both increases are statistically significant. The atypical squamous cells of undetermined significance (ASCUS)/LSIL ratio was reduced by 48% (P < .00001) using AutoCyte PREP when compared to the 1999 conventional Pap smear experience. The unsatisfactory rate was reduced by 70%. AutoCyte PREP demonstrated improved histologic correlation in HSIL cases. CONCLUSION AutoCyte PREP was significantly more effective than the conventional Pap smear for the detection of both LSIL and HSIL. The ASCUS/LSIL ratio and unsatisfactory cases were also significantly reduced.

Prophylactic actinomycin D for high-risk complete hydatidiform mole.

Abstract: Objective To evaluate the effectiveness of one course of prophylactic actinomycin D in reducing the malignant sequelae requiring chemotherapy in high-risk complete hydatidiform mole (CHM) Study design A double-blind, randomized, controlled clinical trial was carried out at King Chulalongkorn Memorial Hospital Sixty cases of CHM classified as high risk were recruited and randomly allocated to a chemoprophylactic or control group Within one week after evacuation of molar tissues, actinomycin D was administered in the chemoprophylactic group Patients in the control group were given only intravenous fluid and analgesic drugs The number of patients with malignant sequelae who required therapeutic chemotherapy after evacuation of hydatidiform mole in each group was recorded Results The incidence of malignant sequelae was 138% (95% confidence interval [CI] = 39-317%) in the chemoprophylactic group and 500% (95% CI = 313-687%) in the control group The risk reduction of malignant sequelae with one course of actinomycin D chemoprophylaxis in high-risk CHM was 724% (95% CI = 267-896%) (P = 005) The side effects of prophylactic chemotherapy were stomatitis, nausea/vomiting, sore throat with oral ulcer and hair loss Conclusion One course of actinomycin D given as chemoprophylaxis decreased by 724% malignant sequelae after evacuation of molar tissue in patients with high-risk CHM This may be particularly beneficial in patients with high-risk CHM who cannot be followed closely, whose compliance is in question and for whom hormonal follow-up is not available or unreliable

Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases.

Abstract: Background Puerperal hematomas can become a life-threatening obstetric emergency. Their incidence is 1 or 2/1,000 deliveries. When mainstay methods of suture and packing fail, arterial embolization becomes an excellent alternative to definitive treatment, laparotomy. Cases A 32-year-old woman, para 2-0-2-2, developed extreme rectal and vulvar pain one hour postpartum. A 12 x 10-cm vulvovaginal hematoma was identified, drained, sutured and packed. Bleeding continued, blood products were administered, and selective angiographic embolization of the pudendal and inferior gluteal arteries was successfully performed. A 31-year-old woman, para 1-0-1-1, developed a left vaginal hematoma immediately postpartum. She failed vaginal packing and underwent angiographic arterial embolization successfully. The patient was discharged on the fourth postpartum day. At six weeks postpartum, neither patient had evidence of hematoma formation. Conclusion In the setting of a puerperal hematoma refractory to conventional first-line therapy, arterial embolization provides a rational, effective alternative for achieving hemostasis with minimal morbidity.

Decreased amniotic fluid index in low-risk pregnancy.

Abstract: Objective To evaluate the perinatal outcomes of pregnancies complicated by isolated decreased amniotic fluid volume (AFI) after 30 weeks' gestation (AFI 5 cm but Study design We retrospectively studied 150 low-risk singleton pregnancies > 30 weeks' gestation with decreased AFI. We also compared the outcomes of 57 pregnancies with AFI 5 cm but Results There were no statistically significant differences between pregnancies with AFI 5 cm but 5 cm but Conclusion With antepartum monitoring, perinatal outcome in low-risk pregnancies with an isolated decreased AFI after 30 weeks' gestation ( 5 cm but

Failed vacuum extraction. Maternal risk factors and pregnancy outcome.

Abstract: Objective To evaluate obstetric risk factors associated with a failed trial of vacuum extraction and to assess its pregnancy outcome. Study design All attempted vacuum extractions between the years 1990 and 1998 were identified, and a comparison of successful and failed trials of vacuum extraction in singleton, vertex deliveries was performed. Results Of 2,111 trials of vacuum extraction, 113 (5.4%) cases were complicated by failed extraction and underwent cesarean section. Those neonates were significantly more likely to be large for gestational age, specifically to weigh > 4,000 g as compared to the controls. Patients lacking prenatal care had significantly higher rates of failed vacuum extraction trials. While cervical and uterine tears were rather rare, parturients who had failed trials of vacuum extraction had significantly higher rates of cervical and uterine tears as compared to those with successful vacuum extractions. This association remained significant after controlling for a previous cesarean section using the Mantel-Hanszel technique. Women from the failed vacuum extraction group had significantly higher rates of postpartum anemia. Pregnancies complicated by failed vacuum extraction had significantly higher rates of intrapartum and postpartum fetal death. Those neonates had significantly higher rates of Apgar scores Conclusion Failed trial of vacuum extraction is associated with adverse maternal and fetal outcomes. Risk factors associated with such failures are fetal weight and lack of prenatal care. Thus, careful estimation of fetal weight should be performed before the procedure, and estimated fetal weight > 4,000 g might be considered a relative contraindication to vacuum extraction, especially among patients who did not have prenatal care.

Fibroids and hypertension. A cross-sectional study of women undergoing hysterectomy.

Abstract: OBJECTIVE: To determine whether uterine fibroids are associated with hypertension. STUDY DESIGN: A total of 543 consecutive women, 41-89 years of age, who underwent hysterectomy in 1984 and 1994 for benign indications at Helsinki University Central Hospital were included in the study. Preoperative information on indications for the procedure, current use of hormone replacement therapy (HRT) or other medication, parity, body mass index and blood pressure (BP) was obtained from medical records. The presence of fibroids was confirmed from the pathology report. Women were classified as hypertensive if they currently used antihypertensive medication, had a history of hypertension without current medication or had a preoperatively measured BP > 140/90 mm Hg. RESULTS: Women with fibroids were significantly younger and more likely to use HRT than the other women. Uterine fibroids were more frequent among hypertensive (42%) than normotensive (37%) women. In logistic regression analysis, fibroids were statistically significantly associated with hypertension (OR 1.8, 95% CI 1.2-2.7). The association between myomas and hypertension was strongest (OR 3.6, 95% CI 1.2-10.9) among women with hysterectomies for benign adnexal tumors. CONCLUSION: Uterine fibroids and/or adnexal tumors may share pathogenic features with the development of hypertension.