Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis

Abstract

To assess the effects of oral contraceptive pills (OCPs) for endometriosis in women after conservative surgery, we performed a search of PubMed, Embase, ISI Web of Science, Cochrane Library, Scidirect, Chinese VIP, CNKI and WANGFANG database. Randomized controlled trials (RCTs) of OCPs in postoperative medical therapy for endometriosis were collected. Articles published as of January 2013 with no language restriction were identified using defined keywords, and 15 studies comprising 1850 patients were included. There was a significantly higher rate of total endometriosis remission [OR?=?2.55, 95% CI (1.68, 3.86), p?<?0.00001] and a lower rate of recurrence [OR?=?0.31, 95% CI (0.22, 0.45), p?<?0.00001] in the OCPs group compared with surgery alone. There appears to be no statistical difference in pregnancy rates between the OCPs group as compared with surgery alone or other hormonal drug treatments in infertility patients. As for the rate of recurrence and complete remission, there were no statistical differences among OCPs and gestrinone, mifepristone or GnRH-a groups. However, OCPs users had less side effects that were more mild as compared with patients using other hormonal treatments.     

Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review

Background  As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA).
Objective  To compare the safety, efficacy and acceptability of MVA with those of EVA for first-trimester abortion.
Search strategy  We searched MEDLINE, EMBASE, Cochrane Library and Chinese Biomedical Database in all language, together with reference lists of retrieved papers.
Selection criteria  Randomised controlled trials comparing MVA with EVA for first-trimester abortion were included. The outcomes are complete abortion rate, uterine perforation rate, blood loss, pain perception and acceptability.
Data collection and analysis  Two reviewers independently extracted the data. Results from the trials were combined to calculate relative risks (RRs) or risk differences for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, together with 95% CIs.
Main results  Ten trials were included, involving 1660 women. Generally, the methodological quality was poor. There were no statistically significant differences, comparing MVA with EVA, in complete abortion rate (RR 1.00; 95% CI 0.99–1.02) and participants' satisfaction (RR 1.02; 95% CI 0.87–1.20). In participants with less than 50 days of gestational age, less blood loss (WMD −1.84; 95% CI −2.45 to −1.23) and less severe pain perception (RR 0.04; 95% CI 0.01–0.12) were reported during the MVA procedure, whereas the operation time was shorter (WMD 0.32; 95% CI 0.02–0.63) in the EVA procedure.
Author's conclusions  There is some evidence that MVA is as effective and acceptable as EVA and might be safer than EVA.     

子宫内膜样腺癌术后辅助放化疗的临床观察

目的评价有高危因素的子宫内膜样腺癌术后辅助放化疗的价值。方法选择宫颈侵犯、G3级、深肌层浸润、淋巴脉管侵犯、腹水细胞学阳性等高危因素的子宫内膜样腺癌268例,140例接受术后放疗,128例接受术后放化疗,比较两组的5年生存率。结果术后辅助放疗和术后辅助放化疗的5年生存率分别为92．14％和92．19％,两者比较,差异无统计学意义（P〉0．05）。而两组的毒性反应比较,术后辅助放化疗组的毒性反应明显增加（P〈0．05）。结论术后辅助盆腔放疗加化疗不能提高具有高危因素的子宫内膜样腺癌的5年生存率,且毒性反应明显增加。     

Hormone therapy in advanced and recurrent endometrial cancer: a systematic review

Endometrial cancer is a hormone-dependent malignancy, and the majority has a precursor phase of endometrial hyperplasia. Histologic subtypes have been recognized with differing natural history. The relationship between hormone response, histology, and molecular profile is not established, but the relevant biology is summarized. This study was a systematic review of the literature to identify which populations should be considered for hormone interventions. Systematic searches were carried out in the English literature for randomized controlled trials and phase II studies of hormone interventions in endometrial cancer. Five randomized trials and 29 phase II studies were identified comprising a total of 2471 patients. In previously untreated patients with grade 1 (G1) or G2 tumors, the response rate for progestogens and the progression-free survival is in the range of 11-56% and 2.5-14 months, respectively. Higher response rates are seen in progesterone receptor-positive cases. Phase II studies comprise the majority of the data and many are of poor quality. There was considerable heterogeneity in patient selection, prior treatment, and type of regimen, and meta-analysis was not possible. G3 or G4 toxicity was less than 5%. We conclude that hormone receptor assessments should be carried out in all patients entered on clinical trials and may aid clinical management in selected cases. Receptor-negative status should not be an absolute contraindication to hormone intervention. Integration of hormone treatment with conventional chemotherapy and growth factor-targeted therapy needs to be explored.     

Intra-abdominal saline irrigation at cesarean section: a systematic review and meta-analysis

Objective: The aim of this study was to examine the evidence guiding intraoperative saline irrigation at cesarean sections.

Methods: We searched “cesarean sections”, “pregnancy”, “saline irrigation” and “randomized clinical trials” in ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, AJOL, MEDLINE, LILACS and CINAHL from inception of each database to April 2015. The primary outcomes were predefined as intraoperative nausea and emesis. The pooled results were reported as relative risk (RR) with 95% confidence interval (95% CI).

Results: Three randomized trials including 862 women were analyzed. Intraoperative saline irrigation was associated with a 68% increased risk of developing intraoperative nausea (RR?=?1.68, 95% CI 1.36–2.06), 70% increased risk of developing intraoperative emesis (RR?=?1.70, 95% CI 1.28–2.25), 92% increased risk of developing post-operative nausea and 84% increased risk of using anti-emetics post-operatively (RR?=?1.84, 95% CI 0.21–2.78) when compared with controls. There were no significant differences between intraoperative saline irrigation and no treatment for post-operative emesis (RR?=?1.65, 95% CI 0.74–3.67), estimated blood loss, time to return of gastrointestinal function, postpartum endometritis (RR?=?0.95, 95% CI 0.64–1.40), urinary tract infection and wound infection.

Conclusion: Intraoperative saline irrigation at cesarean delivery increases intraoperative and post-operative nausea, requiring increasing use of anti-emetics without significant reduction in infectious, intraoperative and postpartum complications. Routine abdominal irrigation at cesarean section is not supported by current data.     

Prevalence of Human Papillomavirus in endometrial cancer: A systematic review and meta-analysis

Objective

HPV is a common sexually transmitted infection and is considered to be a necessary cause of cervical cancer. The anatomical proximity to the cervix has led researchers to investigate whether Human Papillomavirus (HPV) has a role in the etiology of endometrial cancer.

Methods

We conducted a systematic review and meta-analysis to investigate the pooled prevalence of HPV DNA in endometrial cancer. Using meta-regression, we further analyzed whether factors such as geographical region, HPV DNA detection method, publication year and tissue type were associated with HPV prevalence. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for studies providing data on HPV prevalence in cases with endometrial cancer and in controls with normal or hyperplastic endometrial tissue.

Results

We identified 28 papers (29 studies) examining the prevalence of HPV DNA in tumor tissue from endometrial cancer comprising altogether 1026 cases of endometrial cancer. The HPV prevalence varied considerably from 0% to 61.1%. From the random effects meta-analysis, the pooled prevalence of HPV DNA in endometrial cancer was 10.0% (95% CI: 5.2–16.2) with large between-study heterogeneity (I² = 88.2%, p < 0.0001). The meta-regression showed that HPV DNA detection method was statistically significantly associated with HPV prevalence (p = 0.0016): the pooled HPV prevalence was 6.0% (95% CI: 1.5–13.0) using general primers, 18.9% (95% CI: 8.6–32.1) using type-specific primers and 1.0% (95% CI: 0.0–3.6) using non-PCR based methods. None of the other a priori defined variables were statistically significantly associated with HPV prevalence. The pooled OR was 1.43 (95% CI: 0.68–3.00) indicating that the odds of HPV was not increased in cases versus controls.

Conclusions

HPV appears to have a limited or no role in the etiology of endometrial cancer.     

The effect of the levonorgestrel releasing intrauterine system on endometrial hyperplasia: An Australian study and systematic review

Background: The levonorgestrel intrauterine system (LNG-IUS) provides effective contraception and treatment for menorrhagia and is used to prevent endometrial hyperplasia (EH) in women taking unopposed oestrogens.
Aims: The aim of this study was to assess whether the LNG-IUS was also a safe and effective treatment for EH and to conduct a systematic review of the literature.
Methods: A retrospective record review was undertaken in a private gynaecology practice in Brisbane, Australia, and included all women with EH treated with hysterectomy, oral progestins or LNG-IUS between January 2004 and April 2007. Histopathological findings from hysterectomy specimens or endometrial biopsies were used to calculate rates of regression of the EH.
Results: Twenty-one women elected to have a hysterectomy and seven of those (33%) had no persisting hyperplasia at surgery. Twenty-six women had a LNG-IUS inserted at initial hysteroscopy dilatation and curettage or shortly afterwards; seven of those elected to proceed to hysterectomy when their diagnosis was known. Among ten women who used oral progestin treatment, 90% showed initial regression; two with recurrent EH were subsequently treated successfully with LNG-IUS. All 21 women (100%), including one with atypia, treated with LNG-IUS for more than seven weeks had normal endometrial histology on subsequent assessment. No women developed endometrial cancer. Pooled analysis of the published literature gave a 96% regression rate for non-atypical EH treated with LNG-IUS.
Conclusions: These data contribute further evidence that LNG-IUS is a safe and effective method for treating non-atypical EH. Whether LNG-IUS could provide a safe and cost-effective alternative to hysterectomy for atypical EH warrants further examination.     

Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis

To systematically review the literature and to quantitatively compare outcomes and complications following retropubic vs transobturator approach to midurethral slings. We searched PUBMED, OVID, EMBASE, CINAHL, POPLINE, Web of Science, Cochrane Collaboration resources, TRIP, Global Health databases, and abstracts from relevant meetings from 1990 to 2006. We included all studies that compared retropubic and transobturator approaches to midurethral slings and that defined outcomes. We used random-effects models to estimate pooled odds ratios and 95% confidence intervals for objective and subjective failure, complications, and de novo irritative voiding symptoms. Six randomized trials and 11 cohort studies compared transobturator and retropubic approaches to midurethral slings. There was insufficient evidence to support if one approach leads to better objective outcomes. We found no difference in subjective failure between the 2 approaches after pooling data from randomized trials (pooled odds ratio OR 0.85, confidence interval 95% CI 0.38-1.92). The transobturator approach was associated with a decreased risk of complications (pooled OR 0.40, 95% CI 0.19-0.83]). The transobturator approach to midurethral slings is associated with a lower risk of complications; however, it is still unclear if one approach results in superior objective or subjective outcomes.     

Carbetocin for the prevention of postpartum hemorrhage: a systematic review and meta-analysis of randomized controlled trials

Objective: To compare the efficacy and safety profile of carbetocin with other uterotonic agents in preventing postpartum hemorrhage.

Methods: PubMed, Web of Science, Scopus and EBSCOhost were searched for relevant randomized controlled trials published until September 2013.

Results: Carbetocin was associated with a significantly reduced need for additional uterotonic agents (RR?=?0.68, 95% CI: 0.55–0.84, I^2?=?4%) compared with oxytocin in women following cesarean delivery. However, with respect to postpartum hemorrhage, severe postpartum hemorrhage, mean estimated blood loss and adverse effects, our analysis failed to detect a significant difference. Studies comparing carbetocin with syntometrine in women undergoing vaginal delivery demonstrated no statistical difference in terms of risk of postpartum hemorrhage, severe postpartum hemorrhage or the need for additional uterotonic agents, but the risk of adverse effect was significantly lower in the carbetocin group.

Conclusions: Carbetocin has been associated with a similar low incidence of adverse effects to oxytocin and at least as effective as syntometrine and may become an alternative uterotonic agent for the prevention of postpartum hemorrhage. Further studies should be conducted to determine the safety and efficacy profile of carbetocin in women with cardiac disorders and to analyze the cost-effectiveness and minimum effective dose of carbetocin.     

Efficacy and side-effects profile of the ethinylestradiol and etonogestrel contraceptive vaginal ring: a systematic review and meta-analysis

Objective: To assess the efficacy and tolerability (side-effects profile), and compliance of the combined contraceptive vaginal ring (CCVR) compared with combined oral hormonal contraceptives (COC).

Data sources: The PubMed, Embase, POPLINE, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, ClinicalTrials.gov, Clinical Trials Registry Platform (ICTRP) and CINAHL databases were searched.

Methods of study selection: Electronic databases were searched for randomised clinical trials comparing the CCVR with COC with a duration of at least 3 months between 01 December and 15 December 2015. The primary outcome was efficacy. The secondary outcomes were compliance, absence of withdrawal bleeding, breakthrough bleeding, nausea and headache. Heterogeneity was assessed using I² statistic and Cochran's Q statistic. Results were expressed as odds ratios (OR) with 95% confidence intervals (CIs) using random-effects models or fixed-effects models depending on the heterogeneity.

Results: 4368 records were identified, 2844 of which were removed after duplicates and 1524 records were screened. Of these, 1503 were excluded and 21 full text articles were assessed for eligibility. After removing another 7 articles, 14 records were finally included in the qualitative and quantitative analysis. The results show a trend to higher efficacy for the CCVR in preventing pregnancy (Peto OR: 0.52 [95% CI: 0.26–1.04]) and a significantly lower presence of nausea (Peto OR: 0.66 [95% CI: 0.46–0.93]). More cycles were compliant in the CCVR group (Peto OR: 1.22 [95% CI: 1.12–1.32]) and fewer women reported breakthrough bleeding (Peto OR: 0.68 [95% CI: 0.51–0.91]).

Conclusions: Our findings demonstrate that the CCVR is as effective and tolerable as the COC but with a better bleeding profile.     

Contraceptive practices among unmarried women in China, 1982–2017: systematic review and meta-analysis

Objective: Premarital sexual practices and contraceptive prevalence rate (CPR) among unmarried women in China remain unclear. We conducted a systematic review and meta-analysis to estimate CPR and analyse contraceptive methods used by unmarried women between 1982 and 2017.

Methods: Wanfang, The China National Knowledge Infrastructure Database, MEDLINE, PubMed and Web of Science were systematically searched. Data on CPR and use of major contraceptive methods were extracted and pooled using a DerSimonian–Laird random effects model.

Results: Of 188 articles retrieved from five databases, 22 studies met our inclusion criteria. Overall CPR based on a random effects meta-analysis was 32.2% (95% confidence interval [CI] 24.7%, 39.8%). Pooled rates of contraceptive use were 61.4% (95% CI 47.9%, 74.9%) for condoms, 25.9% (95% CI 14.5%, 37.4%) for pills, 19.8% (95% CI 8.9%, 30.8%) for the rhythm method and 25.4% (95% CI 14.2%, 36.7%) for the withdrawal method.

Conclusions: The sexual and reproductive health situation of unmarried women in China seems to have improved little since the 1990s. Our findings may help to optimise reproductive health care programmes and thereby reduce the alarming rates of unplanned pregnancies and abortions among unmarried women in China.     

Use of intravenous immunoglobulin for treatment of recurrent miscarriage: a systematic review

BACKGROUND: Intravenous immunoglobulin (IVIG) is a fractionated blood product whose off-label use for treating a variety of conditions, including spontaneous recurrent miscarriage, has continued to grow in recent years. Its high costs and short supply necessitate improved guidance on its appropriate applications. OBJECTIVE: We conducted a systematic review of randomised controlled trials evaluating IVIG for treatment of spontaneous recurrent miscarriage. SEARCH STRATEGY: A systematic search strategy was applied to Medline (1966 to June 2005) and the Cochrane Register of Controlled Trials (June 2005). SELECTION CRITERIA: We included all randomised controlled trials comparing all dosages of IVIG to placebo or an active control. DATA COLLECTION AND ANALYSIS: Two investigators independently extracted data using a standardised data collection form. Measures of effect were derived for each trial independently, and studies were pooled based on clinical and methodologic appropriateness. MAIN RESULTS: We identified eight trials involving 442 women that evaluated IVIG therapy used to treat recurrent miscarriage. Overall, IVIG did not significantly increase the odds ratio (OR) of live birth when compared with placebo for treatment of recurrent miscarriage (OR 1.28, 95% CI 0.78-2.10). There was, however, a significant increase in live births following IVIG use in women with secondary recurrent miscarriage (OR 2.71, 95% CI 1.09-6.73), while those with primary miscarriage did not experience the same benefit (OR 0.66, 95% CI 0.35-1.26). AUTHOR'S CONCLUSIONS: IVIG increased the rates of live birth in secondary recurrent miscarriage, but there was insufficient evidence for its use in primary recurrent miscarriage.