Kontrazeption bei Frauen mit angeborenen Herzfehlern

Die Gynäkologie - Frauen im Erwachsenenalter mit einem angeborenen Herzfehler (EMAH) werden in Zukunft aufgrund des medizinischen Fortschritts eine immer größere Patientinnengruppe...     

Möglichkeiten der hormonellen Substitution bei gynäkologischen Malignomen

Zusammenfassung Die Hormonersatztherapie nach gynäkologischen Malignomen zur Behebung klimakterischer Beschwerden stellt eine klinische Herausforderung dar. Die Studienlage ist wenig weiter führend, überwiegend handelt es sich um inhomogene Fall-Kontroll-Studien mit geringen Fallzahlen. Unbedenklich scheint eine HRT nach Plattenepithelkarzinom der Zervix uteri sowie nach Vulva- und Vaginalkarzinomen zu sein. Bei Patientinnen nach Ovarialkarzinom muss die meist schlechte Gesamtprognose gegen den Erhalt der Lebensqualität abgewogen werden. Bei Patientinnen nach Endometriumkarzinom Stadium Ia und Ib scheint eine Östrogengabe weitgehend vertretbar zu sein. Der Sinn einer zusätzlichen Gestagengabe muss nach den jüngeren Studien zur Kombinationstherapie von Östrogenen und Gestagenen hinsichtlich des ungünstigen Risikoprofils einer solchen Therapie in Zweifel gezogen werden. Nach fortgeschrittenem Endometriumkarzinom und nach Mammakarzinom kann eine HRT nur als Individualentscheidung nach Versagen anderer Therapieoptionen und bei ausgeprägten klimakterischen Beschwerden in Betracht kommen. Als Therapiealternativen sind in erster Linie SSRI und SNRI zu nennen. Die Rolle des Tibolon und des Raloxifen ist bei nicht ausreichender Datenlage derzeit offen.     

Kontrazeption bei Frauen mit Epilepsie

Epilepsy is one of the most common neurological disorders. For women with epilepsy collaboration between neurologists and gynecologists is crucial. To prevent unintended pregnancies and impaired seizure control the bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme-inducing AEDs (EI-AED) may reduce the efficacy of hormonal contraceptives. To improve contraceptive safety monophasic combined oral contraceptives (COCs) should be used continuously without a hormone-free interval if used in combination with EI-AEDs. The progestin component should be well above the ovulation inhibiting dose. Progestin-only pills (POPs) are likely to be ineffective if used in combination with EI-AEDs. Subdermal progestogen implants (Implanon/Nexplanon/Implanon NXT) are not recommended for patients on EI-AEDs because of published high failure rates. High-dose injectable contraceptives appear to be effective; however they are not the first choice due to potential serious side effects. According to the World Health Organization (WHO) the use of copper intrauterine devices or the new levonorgestrel-releasing intrauterine system (IUS) may be an alternative for many women with epilepsy in need of contraception even if used in combination with EI-AEDs.     

Lung cancer during pregnancy involving the products of conception and a review of the literature

Approximately 1 per 1,000-1,500 pregnancies is complicated by maternal malignancies. Metastatic involvement of the products of conception is a rare event. There have been 62 cases of placental and/or fetal metastatic involvement originating from maternal cancer reported since 1866. Only 14 cases of lung cancer associated with pregnancy have been documented. We report on an additional case involving the products of conception, and the management of lung cancer in pregnancy is discussed based on an extensive review of the literature. The case of a 29-year-old woman presenting during the 31(st) week of gestation with metastatic non small-cell lung cancer to the placenta, liver and bone is described. The mother was delivered by caesarean section of a healthy baby girl during her 32(nd) week of gestation. The mother's postpartum course was complicated by disseminated pulmonary and bony metastases and malignant pericardial and pleural effusions causing the patient's death within 1 month after lung cancer was diagnosed. Malignancies spreading to the products of conception are melanoma (32%), leukemia and lymphomas (15%), breast cancer (13%), lung cancer (11%), sarcoma (8%), gastric cancer (3%) and gynecologic cancers (3%), reflecting malignancies with a high incidence in women of reproductive age. All lung cancers were diagnosed with widely disseminated, inoperable neoplastic disease, including distant metastases in 46%. The mean age was 35.1 years (range, 30-45 years) and 60% of patients had a history of tobacco use. The mean survival was 7.5 months (range: 1-42 months). Placenta involvement was present in 7 out of 15 cases. Fetal involvement was reported in only one case. Because there is no evidence of a direct adverse effect of pregnancy on the course of lung cancer, we recommend delivery at a time when enough fetal maturity can be assumed and the subsequent treatment of the mother.     

Hormontherapie in den Wechseljahren

Until the turn of the century, research indicated that postmenopausal hormonal therapy (HT) was not only helpful for alleviating menopausal symptoms, but it might also prevent the development of diseases associated with age, such as cardiovascular disease, dementia and osteoporosis. Large observational studies supported these hypotheses. However, randomized controlled trials published at the beginning of this century did not confirm many of those benefits seen in the observational trials. Accompanied by spectacular media coverage the enthusiastic preventive approach to use HT was abandoned. HT was considered to have an unacceptable risk profile by many scientists. Afraid of potential risks many women stopped or never started the use of HT. Nevertheless, more recent reanalysis of the available data suggested that the risk/benefit ratio of HT is critically influenced by the timing of initiation of HT. If given early in menopause, soon after cessation of ovarian function, some preventive benefit is very likely, whereas given later on in life HT may have a negative impact on the development and progression of cardiovascular diseases. Today clinicians are left with many unanswered questions, left with the challenge of balancing the potential benefits and risks when taking care of patients seeking help for menopausal symptoms.     

Sexuelle Störungen in der Peri- und Postmenopause

The importance of adequate estrogen levels in preserving vaginal health and preventing dyspareunia in postmenopausal women has long been established. Additionally, estrogens may play an indirect role by priming the brain to be selectively responsive to sexual stimuli. Androgens may also be important for sexual function. Conventional systemic or local vulvovaginal hormone therapy with estrogens may be helpful in restoring vaginal health and sexual function respectively; however it may not be enough as the sole therapeutic agent. Additional testosterone treatment in low-dose regimens may be beneficial, specifically in women with an established cause of androgen deficiency such as surgical menopause. Recent data support hypotheses that androgens may be beneficial also in naturally menopausal women. Local dehydroepiandrosterone (DHEA) appears to have beneficial effects on all the symptoms and signs of vaginal atrophy.     

Kardiovaskuläres Risiko in der Postmenopause und Hormonersatztherapie

More than one third of a woman’s lifetime in the developed countries follows menopause, and the average life expectancy is increasing constantly. With a share of 55%, cardiovascular disease represents the primary cause of death for postmenopausal women. Cardiovascular disease in women manifests at higher age and presents with atypical symptoms. Therefore primary and secondary prevention of cardiovascular disease of postmenopausal women is of increasing interest. Many basic research studies indicate a protective effect of oestrogen for vessels, and several observational studies support these findings. However, randomised controlled studies failed to show secondary prevention of cardiovascular events with oral hormone replacement therapy (HRT). In some studies there was even evidence of increased risk. A trend for primary prevention could be demonstrated only for women with negative cardiovascular anamnesis who obtained oral HRT shortly after menopause. Transdermal oestrogen may be safer with respect to thrombotic risk. When advising patients we must consider our recommendations individually and critically, especially for elderly women with cardiovascular risk.