ML Cu 375 SL宫内节育器紧急避孕多中心临床观察

目的 :评价育龄妇女放置母体乐宫内节育器 ( multiload IUD)作为紧急避孕的效果和可接受性。方法 :1 0 1 3例要求紧急避孕妇女经筛选合格后作为 IUD放置对象。其中经产妇 843例 ,未产妇 1 70例。采用的 IUD为母体乐 3 75 SL( ML Cu3 75 SL)于无保护性生活后 1 2 0 h内放置 ,置器前常规尿妊娠试验以排除妊娠。受试者于置器后下次预期月经后 1周门诊随访。以 Dixon的方法统计避孕效果 ,对经产妇与未产妇的避孕效果和副反应分组进行对比检验。结果 :要求紧急避孕的原因中避孕失败占 5 4.7% ,未采取避孕措施占 45 .3 %。置器后妊娠 2例 ,在两组分别各有 1例 ,避孕有效率经产妇组 97.81 %、未产妇组 90 .96% ,两组对比无显著性差异 ,总有效率为 96.48%、妊娠率为 0 .2 %。根据月经卡记录 ,64 4例 ( 65 % )于置器后有再次性交 ,随访中 2例完全脱落 ,3例部分脱落 ,3 9例因症取出。续用率经产妇 95 .7%、未产妇 80 %。置器后出血和月经改变不严重 ,未发生感染或子宫损伤。结论 :放置带铜 IUD无论对经产妇或未产妇都是一个安全、有效的紧急避孕方法。其优点是长效 ,对有过人工流产史的未产妇也可以选择应用 ,但对有生殖道感染史的妇女要慎重筛选。     

Oral and transdermal hormonal contraception in women after kidney transplantation

AIM: The aim of the study was to assess the safety of low-dose oral or transdermal hormonal contraception in kidney recipients. MATERIALS AND METHODS: Twenty-six kidney recipients, aged 18 to 44 years (mean, 31.0) took low-dose contraceptive pills, and 10 kidney recipients, aged 22 to 36 years (mean, 31.4) used transdermal contraceptive systems. Contraception was administered for a period not shorter than 18 months. At the onset of therapy all patients showed stable graft function. The main indication for therapy was effective contraception. Additional indications were mild ovarian cysts and irregular or profuse menstruations. The pills consisted of 20 to 35 microg of etinyl estradiol and generation III progestogen. The contraceptive patch released 20 microg of etinyl estradiol and 150 microg of norelgesromin daily. RESULTS: No case of pregnancy was noted. Oral contraception was discontinued in two cases, in one case due to profound thrombophlebitis of the lower extremity and in the other case deterioration of liver function. No other side effects or symptoms of intolerance were reported. Hormonal contraception did not significantly influence body mass index, mean blood pressure, serum creatinine, or other biochemical parameters. CONCLUSION: Despite the presence of relative contraindications, mainly arterial hypertension and impaired liver function, hormonal contraception should be considered in female kidney recipients to be a highly effective contraceptive method that additionally regulates menstrual bleeding, protects from development of mild ovarian cysts and seems to positively influence women's well-being. The transdermal mode of administration may diminish the chance for drug interactions and therefore be safer for patients.     

Contraceptive practices in women with cystic fibrosis

There is no literature regarding the contraception practices in female CF patients. A chart review identified 69 women with CF of whom two thirds were using contraception. Eleven different forms of contraception were being used with the oral contraceptive pill the preferred method. Despite theoretical concerns regarding efficacy and toxicity, the choices of contraception are similar to those of the general U.S. population.     

A prospective observational study of the effects of sugammadex on peri-operative oestrogen and progesterone levels in women who take hormonal contraception

Pharmacokinetic modelling suggests that sugammadex may interact with endogenous progesterone and reduce levels by 34% in patients taking hormonal contraception. Due to this potential interaction that may be equivalent to missing one dose of an oral contraceptive pill, both the manufacturer and professional anaesthesia organisations recommend counselling patients to use additional non-hormonal contraception after administration of sugammadex. We performed a prospective observational study examining the changes in serum oestrogen and progesterone concentrations in premenopausal adult women undergoing an operative procedure. Sixty participants who were on hormonal contraception received sugammadex. Two additional control groups were recruited, consisting of 30 participants who were not on hormonal contraception and did not receive sugammadex, and 32 who were not on hormonal contraception and did receive sugammadex. Three blood samples were taken: before sugammadex; 15 min post-sugammadex; and 240 min post-sugammadex or end of operating theatre time. Median oestrogen levels decreased from baseline by around 40% at 240 min in all three groups (p ≤ 0.001). Progesterone levels rose significantly at 15 min (p = 0.002) in patients on contraception then decreased non-significantly to 20% below baseline at 240 min. The decrease in oestrogen and the rise in progesterone could both act to minimise the risk of ovulation and thus protect contraception in this population. We found no evidence of a change in hormone levels that might threaten contraceptive efficacy in women on hormonal contraception receiving sugammadex.     

孕三烯酮用于紧急避孕120例临床观察

目的 :对孕三烯酮 ( R2 3 2 3 )的紧急避孕效果、副反应及对下次月经的影响进行前瞻性临床观察。方法 :1 2 0名要求紧急避孕的妇女 ,单次口服 5mg R2 3 2 3后进行随访 ,观察用药后的副反应和月经情况 ,按 Dixon法推算其避孕有效率。结果 :1 2 0名受试者的总预期妊娠数为 9.0 1 4,实际妊娠 1例 ,避孕有效率为 88.9% ,失败率为 0 .83 %。 1 0 %的受试妇女有轻微头痛、腹痛、恶心、呕吐等副反应 ,无需特殊处理。对下次月经无明显影响。结论 :5mg R2 3 2 3用于紧急避孕时安全有效 ,剂量小 ,副反应少 ,对月经周期无明显干扰。尚有待于大样本多中心研究证实     

Stability in incidence of acute appendicitis. A population-based longitudinal study

BACKGROUND/AIM OF THE STUDY: During the past 50 years, a decrease in incidence of appendicitis has been reported. The various studies were retrospective and based on different data sources. In the present study, we analyze prospectively the incidence of acute appendicitis during a 10-year period in a well defined population of 265,000. METHODS: Prospective registration of all operations performed in patients with suspected acute appendicitis in the catchment area of a single institution. The diagnosis of acute appendicitis was based on histology in all cases. The annual incidence of acute appendicitis was calculated with regard to nonperforated and perforated acute appendicitis. MAIN RESULTS: Between 1989 and 1998, 2,861 patients underwent surgery for suspected acute appendicitis. In 2,232 (78%) patients, acute appendicitis was confirmed histologically. Mean annual incidence was 84/100,000 (95% confidence interval 80 to 88/100,000). Crude incidence remained stable during the study period, with the exception of a significant increase in 1991 followed by a significant decrease the next year. Nonperforated acute appendicitis showed a different incidence pattern as compared to perforated acute appendicitis. CONCLUSION: In our prospective study, the incidence of acute appendicitis remained stable in our well-defined study population during the study period of 10 years. This is in contrast to the majority of studies during the last decades.     

Treatment of menstrual disorders with a combination of norgestrel and ethynyl estradiol

In order to determine the efficacy of oral contraceptives in the treatment of menstrual dysfunction, 44 patients complaining of menstrual disorders were treated with a norgestrel--ethinyl estradiol combination oral preparation (Ovral) at the Vani Vilas Hospital in India in 1969-70. The patients' major complaints included spasmodic dysmenorrhea, dysfunctional uterine bleeding, and menorrhagia with varying indications of fertility and diagnostic confirmation of dysfunction. Those patients who were bleeding heavily at the time of examination were administered 1 tablet of 0.5 mg norgestrel and 0.05 mg ethinyl estradiol 3-4 times daily until the bleeding stopped and then maintained on 1 daily dose along with the other patients with less serious bleeding episodes until Day 21 of treatment. The first day of withdrawal bleeding after cessation of the first treatment was counted as Day 1 and cyclic treatment of 1 tablet daily for 3 weeks and 1 week off was started on Day 5. All 14 patients reporting spasmodic dysmenorrhea had complete relief of symptoms and 1 case of primary infertility conceived after the therapy. Similar results were obtained in the dysfunctional uterine bleeding group. Endometrial biopsies in the metropathic and menorr,agic patients revealed a return to normal endometrial function. The drug was extremely well tolerated in all patients with only 2 patients reporting minimum side-effects. It is concluded that oral contraceptive preparations are highly effective in the therapeutic manipulation of menstrual function.     

Striae distensae of augmented breasts after oral contraceptive therapy

A case of striae distensae (SD) of bilateral augmented breasts following oral contraceptive therapy is presented. Striae maturation and the prevention of additional skin marks was achieved with immediate cessation of oral contraceptive pill therapy and long-term daily topical application of tretinoin cream. It is suggested that patients who are candidates for breast augmentation surgery should be informed of the possible risk of developing SD if they are taking or planning to take the contraceptive pill.     

Optical properties of the breast during spontaneous and birth control pill-mediated menstrual cycles

Mastodynia is correlated with the menstrual cycle. Using frequency-domain near-infrared spectroscopy (FD-NIRS), we investigated changes in breast perfusion in women who were or were not using hormonal contraception. Healthy volunteers, on or not on hormonal contraception, were examined. Optical properties were measured in all quadrants of both breasts, and physiological parameters were calculated. Measurements were repeated every other day during one complete menstrual cycle. Measurements were comparable in all quadrants. Data remained unchanged during the entire cycle in patients using hormonal contraception. However, a biphasic variation of deoxyhemoglobin, oxyhemoglobin, total hemoglobin (tHb), and water content (H₂O) was observed in women not using contraception. tHb and H₂O distinctly increased during the ovulation period and remained elevated throughout the luteal phase. It was concluded that FD-NIRS allows accurate measurement of optical properties of human breasts. As opposed to the menstrual cycles of persons using oral contraception, spontaneous menstrual cycles exhibit biphasic variations of tissue perfusion parameters. These findings are important for the investigation of mastodynia.     

Lyndiol (1 mg)--evaluation of a new low dose oral contraceptive

The combined oral contraceptive (OC) has become one of the most effective methods of controlling India's staggering population growth. Even the less literate of Indian women have accepted the combined OC with considerable enthusiasm, because they understand that it is a method with a 100% guarantee. As progestogen sensitivity is much more marked than sensitivity to estrogens in India, indicated by the incidence of chloasma and amenorrhea, a trial of a new low dose OC was conducted at the Family Planning Welfare Center of Medical College, Calcutta, India. Lyndiol, 1 mg (ethinylestradiol .05 mg and lynestrenol 1 mg) has low progestogen potency. The trial was initiated in July 1973 and has involved 90 patients over 375 cycles. The patients were selected from married women attending the Family Planning Welfare Center for contraceptive advice. The amount of menstrual flow was unaltered in 81 cases and in 10% of cases there was a reduction of flow as compared with pretreatment menstruation. This compared very favorably with highly progestogenic contraceptives that show a reduction of menstrual flow in over 50% of patients. Only 2 patients complained of breakthrough bleeding or spotting in early cycles. 9 patients (10%) complained of nausea and vomiting in early cycles; 5 patients complained of failure of a withdrawal bleeding in early cycles. Some weight gain was observed in 16 patients (17.7%); 4 patients noted a weight loss. Only 6 patients complained of a headache and 5 of breast engorgement. In this study, 6 patients (6.6%) showed a mean rise of systolic blood pressure of 10 mm and a diastolic pressure of 4 mm. The major risk associated with estrogen/progestogen combination is thromboembolism. In India its incidence is rather low. This trial with Lyndiol 1 mg corroborates this since no thromboembolic occurrences were noted. In sum, Lyndiol (1 mg) is an ideal OC, which is available for Indian mothers with a minimum of side effects.     

Acute pelvic inflammatory disease: follow-up in laparoscopically confirmed cases

Laparoscopy was used to verify the diagnosis of acute pelvic inflammatory disease (PID) in 112 patients. The patients were all hospitalized and treated with intensive intravenous antibiotics and followed closely postoperatively for as long as 4 years. A follow-up questionnaire concerning pelvic-abdominal pain, menstrual distrubances, pelvic-venereal infection, contraception, and pregnancy was completed and returned by 81 of the 112 patients. The corrected pregnancy rate was 44% during the follow-up period with only 1 ectopic pregnancy occurring. Reinfection was noted in 11%, residual abdominal or pelvic pain in 21% menstrual abnormalities in 15%, and contraceptive use in 20%. The diagnosis, treatment, and prognosis of acute PID is reviewed briefly.     

上海市夫妇婚后15个月时避孕知识状况及影响因素的分析

目的 :了解夫妇各自于婚礼后 1 5个月时避孕知识状况及影响因素。比较影响双方该时点避孕知识得分的因素。方法 :对上海市近 80 0 0对初婚夫妇自办婚礼后进行 2次随访。由拟合多元线性回归模型比较影响因素。结果 :该时点平均避孕知识得分妻子略高于丈夫 ,平均分别为 1 1 .7及 9.9分 ;对避孕措施一无所知分别为 1 .4%及 6.2 % ;对避孕套一无所知分别为 4.8%及 6.3 %。虽 98%的妻子及 81 %的丈夫知晓口服药 ,但能正确讲述其使用方法仅分别为 1 9%及 1 1 % ;分别有 44 %及 3 0 %未能正确掌握使用避孕套。多元回归模型显示 ,该时点夫妇避孕知识主要来自配偶、自我阅读或家庭内环境的改变。不愿服药或对避孕措施持否定态度的妻子其得分明显偏低。而新婚是否曾用避孕措施或多数性行为仅影响丈夫的得分。结论 :妻子产后近期对避孕措施的了解相对较丈夫被动。计划生育人员及社会媒体有必要消除夫妇对口服避孕药认识的误区 ,指导做好知情选择     

Changes in serum collagen markers,IGF‐I,and Knee joint laxity across the menstrual cycle

Variations in serum markers of collagen production (CICP) and degradation (ICTP), insulin‐like growth factor I (IGF‐I) and anterior knee laxity (AKL) were measured in 20 women [10 with spontaneous cycles (eumenorrheic), 10 using oral contraceptives] over 5 consecutive days at menses (M1–M5, 1st pill week), the initial estrogen rise near ovulation (O1–O5, 2nd pill week), the initial progesterone rise of the early luteal phase (EL1–EL5, 3rd pill week) and post‐progesterone peak of the late luteal phase (LL1–LL5, 4th pill week). ICTP was higher in oral contraceptive women (5.3 ± 1.7 vs. 3.7 ± 1.3 µg/L; p = 0.030), primarily during days near ovulation and the early luteal phase when concentrations decreased in eumenorrheic women (p = 0.04). IGF‐I concentrations increased during menses then decreased and remained lower during the early and late luteal phase in oral contraceptive women, resulting in lower concentrations compared to eumenorrheic women at EL2 and LL1 (p = 0.03). CICP decreased in early and late luteal days (p <0.01), and there was a trend toward lower concentrations in eumenorrheic versus oral contraceptive women (85.7 ± 35.7 ng/ml vs. 123.2 ± 49.8 ng/ml; p = 0.07). Lower CICP and greater IGF‐I concentrations predicted greater AKL across the 20 cycle days in both groups (R² = 0.310 and 0.400). Sex hormone concentration changes across the menstrual cycle are of sufficient magnitude to influence collagen metabolism, and may indirectly influence knee structure and function. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1405–1412, 2012     

Ectopic endometriosis,menstruation, and acute appendicitis: A thought-provoking case

Introduction and importanceEctopic endometrium in the appendix is rare. The relationships between ectopic endometrium in the alimentary tract and digestive symptoms and between digestive symptoms due to ectopic endometriosis and periodic menstruation are controversial. We herein describe the successful treatment of acute appendicitis that we suspect was caused by ectopic endometriosis and periodic menstruation.Presentation of caseA 38.9-year-old multipara with uterine didelphys developed lower abdominal pain during menstruation, and she was clinically diagnosed with acute appendicitis. She received conservative management with cephem antibiotics, and her pain disappeared uneventfully. However, the lower abdominal pain during menstruation later recurred, and she again received conservative treatment. Laparoscopic appendectomy was subsequently performed because for 4 months, her appendicitis-induced digestive symptoms had recurred in association with periodic menstruation. Ectopic endometrial gland proliferations were histopathologically observed in the proper muscular layer of the appendiceal tip. She developed no further episodes of digestive symptoms postoperatively.Clinical discussionEctopic endometriosis of the alimentary tract may be accompanied by digestive symptoms; moreover, these symptoms may be related to periodic menstruation. However, the sensitivity of ectopic endometrium to hormones shows considerable variation among patients. We speculate that the acute appendicitis might have been triggered by ectopic endometriosis in our case because the patient developed repeated digestive symptoms in association with periodic menstruation. Ectopic endometrium may be incidentally observed in histopathological assessments of resected specimens. The therapeutic strategy should be carefully decided on a case-by-case basis.ConclusionWe hope this thought-provoking case provides a timely reminder for gastrointestinal clinicians and general surgeons.     

Relation of pulmonary lymphangio-leiomyomatosis to use of the oral contraceptive pill and fertility in the UK: a national case control study.

BACKGROUND--Pulmonary lymphangioleiomyomatosis is a rare progressive disease of unknown aetiology affecting premenopausal women. Since the oral contraceptive pill has been implicated in its pathogenesis, a case control study was carried out to determine whether women with the disease were more likely to have taken the oral contraceptive pill, and whether the disease was associated with other conditions related to sex hormones including pregnancy, parity, and fibroids. METHODS--All chest physicians in the UK were asked for details of all live patients with pulmonary lymphangioleiomyomatosis; the patient's family doctor was then asked for four age and sex matched control subjects from their patient register. Details of lifetime use of the oral contraceptive pill, pregnancy, parity, history of fibroids, and smoking were obtained from cases and controls. Relative odds of exposure to potential risk factors were estimated by conditional logistic regression. RESULTS--Medical details were obtained from all 23 cases of lymphangioleiomyomatosis identified; questionnaires were completed by 21 cases (one by proxy) and by 46 matched controls of mean (SD) age 43 (10) and 44 (11) years, respectively. The patients had a mean age of 34 (9) years at onset of symptoms and a median (range) time of 2 (0-29) years from onset of symptoms to diagnosis. Compared with control subjects, cases did not differ in the use of the oral contraceptive pill (odds ratio (OR) 0.39, 95% CI 0.09 to 1.68), diagnosis of fibroids (OR 3.12; 95% CI 0.52 to 18.7), age of menarche, menstrual history, or lifetime smoking. They were, however, less likely to have been pregnant (OR 0.14, 95% CI 0.03 to 0.71) or to have had children (OR 0.13, 95% CI 0.03 to 0.67). More pregnancies had ended in spontaneous abortion (28% v 8%) but the proportion of women undergoing spontaneous abortion was similar in cases and controls (OR 2.13, 95% CI 0.47 to 9.3). CONCLUSIONS--This study does not support the hypothesis that use of the oral contraceptive pill is causally associated with the development of pulmonary lymphangioleiomyomatosis. Sex hormones may be involved, however, since patients were less likely to have been pregnant or to have had children, and tended to have had more spontaneous abortions and an increased incidence of fibroids.     

宫腔镜子宫内膜息肉切除术后口服避孕药或放置左炔诺孕酮宫内缓释系统对预防复发的作用

目的探讨子宫内膜息肉宫腔镜手术后口服避孕药或放置左炔诺孕酮宫内缓释系统（曼月乐）对预防复发的效果。方法2009年1月～2011年10月门诊宫腔镜子宫内膜息肉切除术且病理证实为子宫内膜息肉116例,由患者知情选择术后处理方法。34例官腔镜手术后1个月开始应用复方短效口服避孕药12个月（避孕药组）,39例官腔镜术后1个月放置曼月乐（曼月乐组）,43例仅行官腔镜手术切除息肉（对照组）。术后3、6、12个月随访,比较3组复发率,以及月经和血红蛋白情况。结果术后均完成12个月随访。复发率避孕药组2．9％（1／34）,曼月乐组2．6％（1／39）,对照组18．6％（8／43）,3组间复发率差异有显著性（X2=8．649,P=0．013）,对照组复发率是另外2组的6倍。术后3、6、12个月避孕药组和曼月乐组月经量少的构成比均明显高于对照组（P=0．000）。术后12个月避孕药组和曼月乐组血红蛋白明显高于对照组（P〈0．05）。结论官腔镜术后应用复方短效口服避孕药或左炔诺孕酮宫内缓释系统可以降低子宫内膜息肉复发率,不良反应轻,创伤小,值得临床推广。     

A 3-Year Study of Predictive Factors for Positive and Negative Appendicectomies

ABSTRACT

Background: Early and accurate identification or exclusion of acute appendicitis is the key to avoid the morbidity of delayed treatment for true appendicitis or unnecessary appendicectomy, respectively. We aim (i) to identify potential predictive factors for positive and negative appendicectomies; and (ii) to analyse the use of ultrasound scans (US) and computed tomography (CT) scans for acute appendicitis. Materials and Methods: All appendicectomies that took place at our hospital from the 1st of January 2013 to the 31st of December 2015 were retrospectively recorded. Test results of potential predictive factors of acute appendicitis were recorded. Statistical analysis was performed using Fisher exact test, logistic regression analysis, sensitivity, specificity, and positive and negative predictive values calculation. Results: 208 patients were included in this study. 184 patients had histologically proven acute appendicitis. The other 24 patients had either nonappendicitis pathology or normal appendix. Logistic regression analysis showed statistically significant associations between appendicitis and white cell count, neutrophil count, C-reactive protein, and bilirubin. Neutrophil count was the test with the highest sensitivity and negative predictive values, whereas bilirubin was the test with the highest specificity and positive predictive values (PPV). US and CT scans had high sensitivity and PPV for diagnosing appendicitis. Conclusions: No single test was sufficient to diagnose or exclude acute appendicitis by itself. Combining tests with high sensitivity (abnormal neutrophil count, and US and CT scans) and high specificity (raised bilirubin) may predict acute appendicitis more accurately.     

Cardiovascular dynamics in women during the menstrual cycle and oral contraceptive therapy

Littler, W. A., Bojorges-Bueno, R., and Banks, Judy (1974).Thorax, 29, 567-570. Cardiovascular dynamics in women during the menstrual cycle and oral contraceptive therapy. Measurements of pulmonary blood flow and cardiac output have been made in 31 healthy women during the follicular and luteal phases of their menstrual cycle using nitrous oxide whole body plethysmography. The women were divided into three groups: 12 women were receiving oestrogen-progestogen contraceptive pills, 8 were receiving progestogen-only pills, and 11 were using either alternative methods of contraception or none at all. There was no significant difference in the values of cardiac index, pulmonary arterial distensibility, heart rate or systemic blood pressure during the two phases of the menstrual cycle in any of the three groups. When the three groups were compared the cardiac output showed the most significant difference, being greatest in the oestrogen-progestogen group, the progestogen-only group occupying an intermediate position. An increased cardiac output might play a part in the development of systemic hypertension in some women receiving oral contraceptives and could also add a risk to women with pre-existing heart disease.     

Acute appendicitis in late adulthood: incidence, presentation, and outcome. Results of a prospective multicenter acute abdominal pain study and a review of the literature

BACKGROUND: Acute appendicitis is the second most common cause of surgical abdominal disease in late adulthood. It is a serious condition: major errors in management are made frequently and the condition is associated with significant morbidity and mortality. Data collected within a multicenter prospective trial and a literature review were used to analyze diagnostic and therapeutic difficulties in detail. METHODS: In a multicenter intervention study (MEDWIS A 70) data from 2,280 patients with acute abdominal pain were collected prospectively. Patients with histologically proven acute appendicitis, aged 50 years and older (n=102), were compared with younger patients (n=417) to determine differences in presentation, clinical course, and outcome. The basis for the literature review was a Medline search for appendicitis in late adulthood and in the elderly, covering the years 1980-1998. In addition, studies on clinical presentation of acute appendicitis in all age groups were also reviewed and appropriate data were extracted. RESULTS: Patients aged 50 years and older with acute abdominal pain had a significantly higher incidence of surgery. Fourteen percent had acute appendicitis (27% in younger patients), with an increased complication rate (20% vs. 8%) and mortality (3% vs. 0.2%). Significantly more signs and symptoms suggestive of acute abdominal disease and peritonitis were recorded among older patients, reflecting the higher perforation rate (35% vs. 13%). Clinical presentation of appendicitis in younger patients was far more ambiguous. There were no significant differences in outcome between older and younger patients as regards perforations. Perforations are directly associated with treatment delay. Overall delay is a result of late presentation of older patients to hospital and postadmission delay. CONCLUSIONS: Appendicitis in late adulthood is characterized by a delay in treatment, high perforation rates, and unfavorable outcome parameters, all mutually correlating. Older patients with acute abdominal pain are high-risk patients, unlike their younger counterparts. They have to be clinically evaluated by experienced surgeons within a narrow time margin. The problem of late presentation and/or referral should be addressed, perhaps by education of primary care physicians and the public.     

Premenstrual exacerbation of asthma.

Questionnaires and twice daily peak expiratory flow measurements were used to evaluate the effects of the menstrual cycle in asthmatic women. Forty per cent of women reported premenstrual deterioration in their symptoms and this was confirmed by peak flow recordings. No correlations were found between premenstrual exacerbation of asthma and symptoms of premenstrual tension, consumption of aspirin, use of the contraceptive pill, cycle length, or behaviour of asthma during pregnancy.