2 women's Health Newsletter - December 2008

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Mirena IUS - a valuable option in the management of menorrhagia (Heavy periods)

The Mirena IUS has proven to be a most effective method of contraception. A recognized beneificial side effect of the Mirena-IUS is that periods are reduced and this has been incorporated as an option in the management of heavy periods.

Blood loss diminishes quite markedly with a Mirena and this will be a bonus for you if your periods are heavy and painful. You may, however, experience a tendency for spotting through the first two or three months after introduction. A panty liner will usually suffice. The spotting will almost always settle down. Some women stop seeing their periods altogether although the cycle will return once the device is removed. From a medical point of view there is no anxiety if your periods are absent if you have a Mirena. It is a natural phenomenon before puberty, during pregnancy and breast-feeding and after the menopause. Periods are not required by the body to get rid of waste material.

In a recent publication, it has been confirmed that the application of LNG-IUS in reproductive age women seems to decrease fibroid size and increase hemoglobin levels without any significant dysfunction on ovaries.⁰⁸⁰¹

A survey of UK patients' experience Mirena(R) intrauterine system in the treatment of menstrual disorders, acceptability and satisfaction has been conducted in the UK. A retrospective questionnaire was sent to all 1,100 women treated with a Mirena(R) intrauterine system in the Menstrual Disorders Clinic between 1995-2003 at the Queens' Medical Centre, Nottingham. A total of 1,056 (96%) women responded and were included in the study. The majority (73%) of women continued to use the Mirena(R). The women reported a decrease in the heaviness, frequency and pain associated with their period. The commonest side-effect experienced was spotting (19%). Women ranked their satisfaction on a scale of 1-10, with a mean score of 7.07/10. The majority of women are satisfied with the Mirena(R) as a treatment for menstrual disorders. Less than 5% of the women required subsequent operative treatment for menstrual disorders following treatment with the Mirena(R).⁰⁸⁰²

Pelvic Pain - Irritable Bowel Syndrome - Treatment with fibre, antispasmodics and peppermint oil

Pelvic pain is one of the most common reasons for women attending gynecology clinics. About one in three adults have some degree of irritable bowel syndrome (IBS). Not surprisingly, many women have IBS as well as a gynaecological condition such as endometriosis, fibroids or pelvic congestion. It is a matter of clinical judgement whether to treat possible IBS with medication and assess benefit or proceed to other investigations such as laparoscopy.

The effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome has been reviewed in a meta-analysis undertaken in Canada.⁰⁸⁰¹ Randomised controlled trials comparing fibre, antispasmodics, and peppermint oil with placebo or no treatment in adults with irritable bowel syndrome were eligible for inclusion. The minimum duration of therapy considered was one week, and studies had to report either a global assessment of cure or improvement in symptoms, or cure of or improvement in abdominal pain, after treatment. Fibre, antispasmodics, and peppermint oil were all more effective than placebo in the treatment of irritable bowel syndrome.

A study in South Manchester in 1989 found that 52% of women presenting to a gynaecological clinic with pelvic pain had symptoms suggestive of irritable bowel syndrome. Only 8% of those with symptoms suggestive of IBS had a proven gynaecological disorder. One cause of pain associated with intercourse (dyspareunia) is IBS.

The bowel is sensitive to progesterone, which is secreted from the ovary after egg release during the second half of the menstrual cycle (luteal phase - Q 2.13). Progesterone levels increase in pregnancy and this plays a part in the sluggishness of the bowel. Many women are aware of a change in bowel habit during the second half of the menstrual cycle or during their periods. Some studies, but not all, confirm that during the luteal phase the transit time for food to pass through the bowel increases leading to abdominal distension and constipation.

Female Sterilization

Seven hundred seventy women with known parity were recruited to participate in a prospective, multicenter study. Bipolar, low-level radiofrequency energy delivery and porous silicon inserts were used. The inserts were placed bilaterally in the fallopian tube lumen. Subsequent bilateral occlusion was assessed with hysterosalpingography. Overall, bilateral placement success was achieved in 611 of 645 women (95%). Bilateral occlusion was confirmed in 570 of 645 (88.4%). The 1-year pregnancy prevention rate as derived with life-table methods was 98.9%.⁰⁸⁰²

Urinary Stress Incontinence

Urinary stress incontinence is a common problem. Medical treatment may sometimes help. Over the last 15 years, minimally invasive surgical techniques have become popular. Transvaginal tape has been replaced by transobturator tapes in several units.

The effectiveness of tension-free vaginal tape has been compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency in a randomized controlled trial.(Australia Dec 2008).0805 The risk ratio of repeat surgery was 2.6 (95% CI 0.9-9.3) times higher in the transobturator tape group compared to transvaginal tape. It was concluded that retropubic TVT is a more effective operation than the transobturator tape sling in women with urodynamic stress incontinence and intrinsic sphincter deficiency.

Endometrial Cancer Surgery - Robots

Traditionally, surgery for endometrial cancer has been performed by laparotomy. Minimally invasive techniques, notably laparoscopy, have become increasingly popular.

Robotic surgery is being developed. The instruments are moved by a robot with the surgeon sitting away from the patient at a console. The advantages are that there is less pain for the patient, the patient can return to normal activity more quickly and the scar is cosmetically better. This has the benefits of reduced post-operative pain, earlier return to normal activities and an improved scar.  

In Sandford, USA (December 2008). one hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging.⁰⁸⁰¹ All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic). The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%). Average return to normal activity for the robotic patients was significantly shorter than those undergoing laparotomy (24.1 days versus 52 days) and those undergoing laparoscopy (31.6 days). Lymph node retrieval did not differ between the 3 groups (robotic 17 nodes, laparotomy 14 nodes, laparoscopic 17 nodes). 

Premature labour

Premature delivery is associated with increased mortality and morbidity for the baby. In developed countries, outcomes have improved with better neonatal care. Administration of steroids to the mother who is in premature labor has proven to be beneficial and tocolytics (drugs to suppress premature labor) may delay delivery to allow the steroids to achieve their goal.

It has proven difficult to confirm that tocolytic agents are effective in suppressing premature labour. There is no real evidence that any of these agents are effective in preventing premature labour or preventing it from recommencing. It has recently been shown that when compared with placebo, maintenance nifedipine tocolysis did not confer a large reduction in preterm birth or improvement in neonatal outcomes.⁰⁸⁰¹

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December - 1st Newsletter

What is MR Guided Focused Ultrasound (MRgFUS) and what is its role in the management of fibroids?

The author was privileged to be invited to the first UK symposium on  MR Guided Focused Ultrasound - held in London - 26th November 2008

MR Guided Focused Ultrasound MRgFUS offers a new and exciting option for women who have symptoms attributable to fibroids, who require surgical intervention and who wish to retain their uterus. The procedure is non-invasive.

What are fibroids?

• Uterine fibroids (leiomyomas) are benign tumors that grow within the muscular wall of the uterus. 
• They are the most common pelvic tumors in women, with a prevalence of 20-40% during middle reproductive age. 
• Prevalence of 70% of all women by age 50.
• 20% of gynaecological consultations relate to fibroids.
• They are more common in women of African-Caribbean origin. 
• USA $6.5 billion for cesarean sections and $2.0 billion for fibroid surgery in 2004.

Fibroid Symptoms

Many women are unaware that they have fibroids but others have reduced quality of life because of:-

• Heavy periods
• Pelvic pain or pressure
• Pressure on the bladder leading to increased need to urinate
• Pressure on the bowel which can lead to constipation and/or bloating
• An enlarged abdomen which is sometimes mistaken for pregnancy
• Fertility Problems

Treatment options for fibroids

There are several treatment options to relieve symptoms associated with fibroids including:

• MR Guided Focused Ultrasound - NEW TREATMENT
• Medical
• Surgical

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Down Syndrome Screening

Healthcare systems appear to facilitate informed choices in the context of prenatal screening for Down syndrome screening less well for women from minority ethnic groups and those who are socioeconomically disadvantaged than for other women.^0501, While most pregnant women in England are offered prenatal screening for Down syndrome, approximately 1 in 10 is not. Asian women are less likely than White women to report being offered Down syndrome screening and are less likely to have a screening test when offered.²⁰⁰⁸

Down syndrome (mongolism, Down's syndrome, or trisomy 21), which is associated with typical facial features and reduced mental ability, is due to an extra chromosome 21 (genes - chromosomes). The disorder was identified as a chromosome 21 trisomy in 1959. The condition is characterized by a combination of major and minor differences in structure. Often Down syndrome is associated with some impairment of mental ability and physical growth as well as facial appearance. A few have severe mental disability but the majority enjoy a good life.

Many of the common physical features of Down syndrome also appear in people with a standard set of chromosomes. They may include:-

• a single transverse palmar crease (a single instead of a double crease across one or both palms),
• an almond shape to the eyes caused by an epicanthic fold of the eyelid, upslanting palpebral fissures (the separation between the upper and lower eyelids),
• shorter limbs,
• a larger than normal space between the big and second toes,
• and protruding tongue.

Health concerns for individuals with Down syndrome include:-

• a higher risk for congenital heart defects,
• gastroesophageal reflux disease,

Is screening for abnormality in the fetus justifiable?

The question of screening for foetal abnormality is never an easy one.

Some would find the thought of caring for a handicapped child intolerable whereas others believe the practice of pregnancy termination is unacceptable.

1. Many couples elect to continue the pregnancy and the obstetrician in collaboration with the paediatrician can counsel on what is to be expected and the treatment options for the baby.
2. Other couples decide that they do not wish the pregnancy to continue and pregnancy termination can be arranged. Counselling may be offered to provide support for you to come to terms with a decision to discontinue a planned pregnancy.

You will also need advice on the chance of recurrence in another pregnancy.

Dysmenorrhea associated with endometriosis - Controlled trial demonstrates efficacy of combined oral contraceptive pill.

In a double-blind, randomized, placebo-controlled trial one hundred patients with dysmenorrhea associated with endometriosis most enrolled patients had radiologic evidence of endometriosis rather than surgical diagnosis. Patients were randomly assigned to receive either monophasic OCP (ethinylestradiol plus norethisterone) or placebo.  Total dysmenorrhea scores assessed by the verbal rating scale were significantly decreased at the end of treatment in both groups. From the first cycle through the end of treatment, dysmenorrhea in the OCP group was significantly milder than in the placebo group. The volume of endometrioma (larger than 3 cm in diameter) was significantly decreased in the OCP group, but not in the placebo group. No serious adverse events related to using OCPs occurred. This present study clearly demonstrated for the first time that OCPs could be used to effectively and safely treat pain associated with endometriosis.²⁰⁰⁸

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Cesarean Section Rate 18th November 2008

Cesarean section rates are rising and account for more than 30% of childbirths in the USA.

An article in the Daily Mail (November 2008) highlights the problem.

This rise can be attributed to:

• Relative safety of surgery with improvement in anesthesia, availability of blood transfusion and antibiotics.
• Greater emphasis on quality of offspring rather than quantity.
• Patient preference based on claimed benefits of planned caesarean section including greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience.

The potential disadvantages, include increased risk of major morbidity or mortality for the mother, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

The decision on optimum mode of delivery is the most commonly encountered question in clinical practice across all medical disciplines.

The number of factors to be taken into account is greater than in any other clinical situation across all medical disciplines.

There is undoubtedly a risk of litigation issue colouring obstetric decision making. An obstetrician is more likely to be subjected to litigation because a cesarean section was not performed or was perceived to have been performed too late than for complications of surgery. In the current climate, it is likely that cesarean sections are likely to continue rising.

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Treatment For Unexplained recurrent  miscarriage

It is an understandable cry from the heart from couples who experience the devastation of recurrent miscarriage that there must be one explanation and one perfect treatment. It is only in the last ten years that we have begun to find some treatable explanations for recurrent miscarriages.

Badawy et al²⁰⁰⁸  have reported on the efficacy of early thromboprophylaxis with low-molecular weight heparin (LMWH) in women with a history of recurrent first trimester spontaneous abortion or miscarriages without identifiable causes vs no treatment in a randomised prospective study. There was a significant difference in the incidence of both early (4.1% vs 8.8%) and late miscarriages (1.1% vs 2.3%) in heparin group. However, the mean birth weight was significantly higher in the heparin treated group. They concluded that LMWH seems to be a safe drug and effective in significantly reducing the incidence of recurrent miscarriages of unknown aetiology when given in the first trimester and continued throughout pregnancy.

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