Patient Information: How much information do modern patients require?

February 2009 Newsletter

Is it essential to remove the neck of the womb at hysterectomy - Total or Sub-Total Hysterectomy?

In a recent Norwegian study⁰⁸⁰¹, 315 consecutive patients were sent a questionnaire sent to patients who underwent a laparoscopic supracervical hysterectomy (sub-total) during 2004 and 2005. Persistent vaginal bleeding and pelvic pain, patient acceptability of such symptoms and patient satisfaction following LSH were evaluated. A total of 240 women (78%) completed the questionnaire. About 24% reported experiencing vaginal bleeding up to 3 years following their hysterectomy, although this was rated as minimal in 90% of cases. Women operated on by less experienced surgeons were more likely to report vaginal bleeding following surgery. ANinety per cent of women reported being satisfied with their surgery. It was concluded that although vaginal bleeding and pelvic pain are frequently observed following LSH, these symptoms are significantly reduced and patient satisfaction is high.

This paper has again raised the question as to whether the cervix should routinely be removed routinely during hysterectomy - sub-total hysterectomy.

Sleep Problems and the Menopause

In clinical practice many menopausal women complain of problems sleeping. Frequently, they have severe night sweats to the point that they have to change clothing. I have little doubt that HRT can assist.

Interestingly, a study from Finland has found that the menopause does not account for objective sleep quality.⁰⁸⁰¹Twenty-one premenopausal (45-51 years), 29 postmenopausal (59-71 years) and 11 young (20-26 years, using oral contraceptives) women were recruited. Polysomnography was used to measure objective sleep quality. Subjective sleep quality, sleepiness and mood were assessed using questionnaires. Cognitive performance was investigated by means of three attentional tests.

Results:

Total sleep time in pre- and postmenopausal women was similar (404.9 and 384.7 minutes), but shorter than in young women. The increase in sleep complaints after menopause was not associated with sleepiness or disturbances in objective sleep quality, mood or cognitive performance.

A further study by the same group of Finnish researchers found no benefit on sleep with HRT on pre-menopausal or late menopausal women but they did not study potential HRT benefits on sleep immediately around the menopause.⁰⁸⁰²

Caffeine consumption and adverse effects in pregnancy

Caffeine is found in coffee, chocolate and cola drinks. It has previously been shown that caffeine may reduce fetal growth but the level of intake above which the risk was increased was unknown.

2635 low risk pregnant women recruited between 8-12 weeks of pregnancy. Quantification of total caffeine intake from 4 weeks before conception and throughout pregnancy was undertaken with a validated caffeine assessment tool. Caffeine half life (proxy for clearance) was determined by measuring caffeine in saliva after a caffeine challenge. Caffeine consumption throughout pregnancy was associated with an increased risk of fetal growth restriction  for 100-199 mg/day, 1.5 (1.1 to 2.1) for 200-299 mg/day, and 1.4 (1.0 to 2.0) for >300 mg/day compared with <100 mg/day. Mean caffeine consumption decreased in the first trimester and increased in the third.  Caffeine consumption during pregnancy was associated with an increased risk of fetal growth restriction and this association continued throughout pregnancy. Sensible advice would be to reduce caffeine intake before conception and throughout pregnancy.⁰⁸⁰¹

Stem Cells - An exciting area of research with multiple treatment potentials

The recently reported transplant of a bioengineered bronchus in Spain highlights the advances being made with stem cell research and treatment involving stem cells.

Stem cells are  found in most organisms. They are characterized by the ability to renew themselves into a diverse range of specialized cell types. The two broad types of mammalian stem cells are: embryonic stem cells  and adult stem cells that are found in adult tissues.In embryos, stem cells can differentiate into all of the specialized tissues. In adults, stem cells act as a repair system for the body, replenishing specialized cells, but also maintain the normal turnover of regenerative organs, such as blood, skin or intestinal tissues.

Stem cells can now be cultured and transformed into specialized cells with characteristics consistent with cells of various tissues such as muscles or nerves. Adult stem cells from a variety of sources, including umbilical cord blood and bone marrow, are routinely used in medical therapies.

Several recent findings in stem cell biology have resulted in new opportunities for the treatment of reproductive disease. Endometrial regeneration can be driven by bone marrow derived stem cells. This finding has potential implications for the treatment of some uterine disorders.The ovaries have been shown to contain stem cells that form oocytes in adults and can be cultured in vitro to develop mature oocytes.

While we are just beginning to understand stem cells and many key questions remain, the potential advantages of stem cells in reproductive biology and medicine are becoming increasingly apparent.⁰⁹⁰¹

A common factor in seemingly unrelated Obstetric and Gynaecological Enigmas?

Bhattacharya⁰⁸⁰¹ identified 1561 women who had a first miscarriage (1404 in the first trimester and 157 in the second trimester), 10 549 who had had a previous live birth (group A) and 21 118 primigravidae (group B). The miscarriage group faced a higher risk of pre-eclampsia , threatened miscarriage , induced labour , instrumental delivery , preterm delivery  and low birthweight  than group A. It was concluded that an initial miscarriage is associated with a higher risk of obstetric complications.

If there is a relationship between miscarriage and increased obstetric risk in the next continuing pregnancy the question arises as to the causation. The author of this website has hypothesised that subclinical bacteria within the uterine cavity (bacteria endometrialis) could explain a number of gynaecological and obstetric enigmas.⁹⁹⁰¹