Cervical intraepithelial neoplasia recurrence after conization in HIV-positive and HIV-negative women

Objectives

To evaluate the recurrence rates of cervical intraepithelial neoplasia (CIN) in a cohort of HIV-infected and noninfected women who underwent the loop electrosurgical excision procedure (LEEP).

Methods

A prospective cohort study of 94 HIV-positive and 107 HIV-negative women, both with CIN, treated with LEEP. The diagnosis of recurrence was established after biopsy. The Kaplan-Meier method was used for survival analysis and multivariate analyses were carried out using the Cox proportional hazards regression model.

Results

There was a predominance of low-grade lesions in HIV-positive compared with HIV-negative women (P < 0.01). Recurrence was more frequent with compromised margins and glandular involvement (P < 0.01). A multivariate analysis showed that HIV-infection, glandular involvement, and positive margins were independently associated with recurrence of lesions.

Conclusions

Recurrence rate of CIN in HIV-positive women was higher than in HIV-negative women. The factors associated with recurrence were HIV infection, glandular involvement, and positive margins.     

Phenotypic expression, body mass index and insulin resistance in relation to LH levels in women with polycystic ovary syndrome

Objective

To evaluate LH levels in women with the classic (1990 criteria) and the newer (2003 criteria) PCOS phenotypes, and to examine the impact of BMI and insulin resistance indices on hormone levels.

Study design

In this controlled clinical study 936 women with PCOS, classified as classic (n = 729) and newer (n = 207), and 204 controls were included. All women were divided into normal-weight (BMI < 25 kg/m²) and overweight plus obese (BMI ≥ 25 kg/m²). Serum LH, FSH, anthropometrics, androgens, fasting insulin and glucose, HoMA-IR, number of follicles, and ovarian volume were assessed.

Results

Women with classic PCOS presented significantly higher LH and LH/FSH ratios, and lower glucose/insulin levels than those with the newer phenotype and controls. Overweight plus obese women of all groups had lower LH levels than normal-weight women. Independent positive correlations between LH and androgens and negative correlation between LH and BMI were found.

Conclusions

The higher LH concentrations of the classic phenotypes of PCOS could be attributed to the higher androgen levels, which desensitize the hypothalamus to the negative feedback regulation by progesterone. Moreover, the lower LH levels of overweight plus obese women of all groups could be attributed to the increased peripheral aromatization of androgens to estrogens in adipose tissue leading to suppression of LH secretion.

Condensation

Both normal-weight and overweight women with classic PCOS phenotypes present higher LH levels and LH-to-FSH ratios than women with similar BMI but the newer phenotypes.     

Home administration of misoprostol for early medical abortion in India

Objective

To assess the efficacy and acceptability of home administration of misoprostol for early medical abortion in Indian family planning clinics.

Methods

In this prospective cohort study, consenting pregnant women (n = 599) with amenorrhea of 8 weeks or less seeking termination of pregnancy received 200 mg of oral mifepristone followed 48 hours later with 400 µg of oral misoprostol, administered either at home or at the clinic.

Results

Almost all women (88.4%) chose to take misoprostol home. There was no statistical difference in success rates between home and clinic users (89.0% vs 92.4%, Pearson χ² = 0.7; P = 0.395). Most women in both the home (90.7%) and clinic (92.3%) groups were satisfied or very satisfied with the procedure.

Conclusion

Home administration of misoprostol is safe and feasible for introduction into medical abortion services in India.     

Success rate, quality of life, and descriptive analysis after generalized endometrial ablation in an obese population

Objective

To describe the success rate of and the quality of life after global endometrial ablation in an obese population.

Methods

A follow-up survey was mailed to 72 women who had undergone global endometrial ablation. The survey included a menorrhagia-specific NovaSure endometrial ablation questionnaire. The mean follow-up time was 2.5 years.

Results

Forty-four women (61%) responded, with a mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30.5. Overall, patients reported a decrease in missed social activities, in inability to perform activities of daily living, in missed work days, in bleeding tendencies, and in pain. The amenorrhea rate was 37%, and the success rate (those not requiring any further therapeutic treatment) was 86%. Patient satisfaction was 93%.

Conclusion

Global endometrial ablation improved quality of life for obese women with menorrhagia and had a high rate of satisfaction, even for patients not achieving amenorrhea. Patients with a BMI of more than 34 showed a trend toward failure and a higher rate of hysterectomy.     

Polycystic ovary syndrome and abnormalities in glucose tolerance

Objectives

To compare the prevalence of abnormal glucose tolerance (AGT) among women with polycystic ovary syndrome (PCOS) and controls, and assess risk factors associated with PCOS.

Method

A fasting oral glucose tolerance test after ingestion of 75 g of glucose was administered to 264 women with and 116 without PCOS. Moreover, fasting glucose, insulin, and testosterone levels were measured in the women with PCOS. Body mass index (BMI), waist-to-hip ratio (WHR), and homeostasis model assessment-insulin resistance (HOMA-IR) were calculated for each woman with PCOS.

Results

The AGT prevalence was 14.4% in the PCOS group and 11.2% in the control group (P = 0.17). The women with both PCOS and AGT had significantly higher BMIs, WHRs, testosterone levels, and HOMA-IR values than those with normal glucose tolerance.

Conclusion

While AGT was not associated with PCOS, the women with both PCOS and AGT were significantly more obese, hyperandrogenic, and insulin resistant than those with PCOS and normal glucose tolerance.     

Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids

Objectives

To determine whether women will experience permanent amenorrhea following uterine artery embolization for fibroids, and whether rates of onset differ in the long term according to age at the time of the procedure.

Methods

Over 77 months, 211 consecutive eligible women were grouped by age (group A, < 40 years [n = 39]; group B, 40-44 years [n = 98]; and group C, ≥ 45 years [n = 74]) and the cumulative rates of onset of permanent amenorrhea were compared between the groups.

Results

The likelihood of incurring permanent amenorrhea was significantly higher in group C. The cumulative rates in groups A, B, and C were 0%, 1.4%, and 19.7% at 3 years and 0%, 11.2%, and 40.4% at 6 years.

Conclusion

The rates of onset of permanent amenorrhea changed over time and differed according to age at the time of the procedure, with little likelihood of permanent amenorrhea at 6 years for women younger than 40 years at the time of the procedure.     

Efficacy of mifepristone in reducing intermenstrual vaginal bleeding in users of the levonorgestrel intrauterine system

Objective

To evaluate the efficacy of mifepristone to reduce intermenstrual bleeding in levonorgestrel intrauterine system (LNG-IUS) users.

Method

In this prospective, open-label, comparative study, 36 women using the LNG-IUS for menorrhagia received 100 mg of mifepristone every 30 days for 3 months (group 1). Fifty age-matched LNG-IUS users who did not receive any drugs were used as the comparison group (group 2). Menstrual bleeding days, pictorial blood loss assessment chart (PBAC) score, and intermenstrual bleeding/spotting days were compared between the 2 groups at 3 months (during treatment) and at 6 months (3 months post treatment).

Results

Baseline characteristics were comparable between the groups. At 3 months, median duration and episodes of intermenstrual bleeding/spotting were significantly lower in group 1 compared with group 2 (6 vs 12.5 days, P = 0.01; 2.5 vs 3, P = 0.05, respectively). More women were satisfied with the LNG-IUS in the mifepristone group compared with the control group (75% vs 44%; P = 0.004). At 6 months, the median duration of intermenstrual bleeding/spotting was significantly lower in group 1 compared with group 2 (6 vs 15 days; P = 0.008).

Conclusion

Mifepristone was effective in reducing the number of episodes and duration of intermenstrual bleeding/spotting in LNG-IUS users.     

Breastfeeding and contraception use among women with unplanned pregnancies less than 2 years after delivery

Objective

To examine breastfeeding and contraceptive use after the lactational amenorrhea method (LAM) criteria were no longer met.

Methods

Two hundred and thirty-three parous Egyptian women with unplanned pregnancies less than 2 years after delivery completed a questionnaire examining breastfeeding practice and contraceptive use.

Results

The majority of women (81.5%) with unplanned pregnancies within 2 years of delivery were breastfeeding at conception. Of these women, 36.3% had used a method of contraception other than LAM compared with 60.5% of women who had weaned (P < 0.05). Among the breastfeeding women, 61.2% failed to use contraception because they believed breastfeeding would prevent pregnancy.

Conclusion

Breastfeeding women with unplanned pregnancies were less likely to have used contraception than women who had weaned, suggesting that prolonged breastfeeding contributes to unmet contraceptive need.     

Body Mass Index and spontaneous miscarriage

Objective

We compared the incidence of spontaneous miscarriage in women categorised as obese, based on a Body Mass Index (BMI) >29.9 kg/m², with women in other BMI categories.

Study design

In a prospective observational study conducted in a university teaching hospital, women were enrolled at their convenience in the first trimester after a sonogram confirmed an ongoing singleton pregnancy with fetal heart activity present. Maternal height and weight were measured digitally and BMI calculated. Maternal body composition was measured by advanced bioelectrical impedance analysis.

Results

In 1200 women, the overall miscarriage rate was 2.8% (n = 33). The mean gestational age at enrolment was 9.9 weeks. In the obese category (n = 217), the miscarriage rate was 2.3% compared with 3.3% in the overweight category (n = 329), and 2.3% in the normal BMI group (n = 621). There was no difference in the mean body composition parameters, particularly fat mass parameters, between those women who miscarried and those who did not.

Conclusions

In women with sonographic evidence of fetal heart activity in the first trimester, the rate of spontaneous miscarriage is low and is not increased in women with BMI > 29.9 kg/m² compared to women in the normal BMI category.     

Minimal deviation adenocarcinoma of the uterine cervix

Background

Precise preoperative diagnosis of minimal deviation adenocarcinoma (MDA) of the uterine cervix is often difficult because the histological features of MDA closely resemble those of normal cervical glands.

Objective

To review the developments in the diagnosis and treatment of MDA over the past 35 years.

Search strategy

We performed a meta-analysis of all case reports published in the English and Chinese languages between 1975 and 2009 that included a histopathologic diagnosis of MDA. Pooled odds ratios and 95% CIs were calculated for comparisons and analyzed.

Results

The histopathologic diagnosis of MDA remains difficult and is currently based on antigen detection by immunohistochemistry. Cytologic assessment and routine biopsy have low detection rates for MDA. Cross-sectional imaging techniques are helpful but a deep cervical biopsy or cervical conization is necessary for a definitive diagnosis. The mean survival is about 5 years for patients with stage I, 38.1 months for patients with stage II, 22.8 months for patients with stage III, and 5.4 months for patients with stage IV MDA.

Conclusion

Early diagnosis and treatment are key to improving prognosis and survival in patients with MDA.     

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

Objectives

The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).

Study design

A retrospective case-control study of women with IUGR (n = 27) and healthy controls (n = 123) in the third trimester of pregnancy.

Results

The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07 ± 24.72% vs 65.20 ± 17.95% (p < 0.005) and 42.88 ± 11.01% vs 56.64 ± 13.30% (p < 0.0001), respectively. No significant correlation was found between total protein S and IUGR.

Conclusions

Levels of functional and free protein S are correlated with IUGR.     

Non-uptake of colposcopy in a resource-poor setting

Objective

To determine the rate of acceptance/refusal of colposcopy and the reasons for refusal by women referred for the procedure in southeast Nigeria.

Methods

An audit was performed of the computerized database for all women referred for colposcopy at the University of Nigeria Teaching Hospital, Enugu, from August 1, 2009, to July 31, 2010. The characteristics of those who accepted colposcopy were compared with those who refused the procedure. An interviewer-administered questionnaire was used to assess reasons for refusal and the subsequent treatment chosen.

Results

During the study period, 154 women were referred for colposcopy: 103 (66.9%) accepted and 51 (33.1%) refused. Those who refused were younger and tended to be nulliparous (P = 0.029 and P = 0.004, respectively). The most common reasons for refusal were fears of possible diagnosis of cervical cancer and compromise of future fertility. Most women who refused resorted to spiritual healing.

Conclusion

The rate of refusal of colposcopy in southeast Nigeria was high, indicating an urgent need for appropriate remedial measures instituted through intensive education of women regarding cervical cancer and its prevention. Targeted counseling should be initiated early as part of prescreening counseling.     

Assessment of ischemia-modified albumin level in patients with recurrent pregnancy loss during the first trimester

Objective

The finding that ischemia-modified albumin (IMA) is increased in pre-eclamptic pregnancy suggests a role for IMA as a potential biomarker for abnormal placental development related to miscarriage. This study was undertaken to evaluate IMA levels in women with recurrent pregnancy loss (RPL).

Study design

This case-control study was performed between March 2008 and September 2009, at the Department of Obstetrics and Gynecology of Meram School of Medicine. Serum IMA and albumin concentrations were assessed in 43 women with a history of two or more unexplained first trimester miscarriages (group 1), and 42 healthy pregnant women (group 2) in the first trimester. IMA, adjusted IMA and albumin concentrations were compared between the groups. Statistical analysis was performed using Student's t-test and Mann-Whitney U test.

Results

IMA and adjusted IMA levels were significantly higher in women with RPL (1.11 + 0.08 and 1.09 + 0.09, respectively) compared to women in group 2 (0.88 + 0.10 and 0.88 + 0.11, respectively). Albumin levels in group 1 were significantly lower compared with group 2. There was a negative correlation between IMAand albumin levels in each group.

Conclusion

Maternal IMA levels appear to be elevated in women with early RPL. This finding may suggest that an abnormally high hypoxic intrauterine environment may be associated with abnormal placental development that contributes to early miscarriage.     

Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Objective

To evaluate the reproductive outcomes of patients with a uterine septum and otherwise unexplained infertility who underwent hysteroscopic metroplasty, and to compare them with those of patients with the same diagnosis who did not have hysteroscopic metroplasty.

Methods

The present retrospective study included 127 patients with diagnosis of a uterine septum and otherwise unexplained infertility. The reproductive outcomes of 102 patients who underwent hysteroscopic metroplasty (group 1) and 25 patients who rejected the operation (group 2) were compared.

Results

Of the 102 patients who underwent hysteroscopic metroplasty, 44 (43.1%) were able to achieve pregnancy, as compared with 5 (20%) of the 25 patients who did not undergo the operation (P = 0.03). The abortion rate was 11.4% (5/44) in group 1, compared with 60% (3/5) in group 2 (P = 0.02). The live birth rate was 35.3% (36/102) in group 1, as compared with 8% (2/25) in group 2 (P = 0.008).

Conclusions

The results indicate that hysteroscopic metroplasty improves reproductive outcome for patients with a uterine septum and otherwise unexplained infertility.     

Three-dimensional power Doppler imaging in the diagnosis of polycystic ovary syndrome

Objective

To determine the role of three-dimensional (3D) power Doppler imaging in the diagnosis of polycystic ovary syndrome (PCOS).

Methods

Pulsatility index (PI) and resistance index (RI) of the uterine artery and ovary were measured by two-dimensional (2D) Doppler imaging, while vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured by 3D power Doppler in 25 patients with PCOS and 25 women with normal menstrual cycles used as a control group.

Results

Uterine artery PI and RI were significantly higher (P < 0.001) and ovarian PI and RI were significantly lower (P < 0.001) in women with PCOS compared with controls. Ovarian VI and VFI were significantly higher in women with PCOS compared with the control group (P < 0.001).

Conclusion

3D power Doppler indices were higher in women with PCOS than in the control group and were positively correlated with 2D color Doppler indices, and clinical and hormonal parameters. High 3D power Doppler indices may be useful as one of the diagnostic criteria for PCOS.     

Laparoscopic lymph node dissection should be performed before fertility preserving treatment of patients with cervical cancer

Objective

The aim of this study is to assess our results of treatment of women with stage I cervical cancer > 2 cm in diameter seeking fertility preservation. Treatment consisted of Laparoscopic Pelvic and Paraaortic Lymphadenectomy (LPPLND), and when no nodal metastasis was detected, neoadjuvant chemotherapy (NACT) followed by radical vaginal trachelectomy (RVT). Patients with positive lymph nodes underwent primary chemoradiation.

Methods

A cohort of women younger than 40 years of age with stage I disease > 2 cm who underwent LPPLND and either NACT and RVT or chemoradiation. Oncological outcome was evaluated prospectively.

Results

Eighteen women were eligible for this study. Twelve (67%) women were diagnosed with metastasis in one or more pelvic and/or paraaortic lymph nodes, and thus received primary chemoradiation. After a mean follow-up of 25.5 months, three out of these 12 women (25%) developed a recurrence. Six women (33%) underwent NACT and RVT. Three patients experienced complete response to NACT and three patients showed more than 50% tumor size reduction. After a mean follow-up of 30.6 months all six women are free of recurrence. One patient delivered a healthy infant.

Conclusions

Staging LPPLND allows separating patients in high or low recurrence risk groups. NACT and RVT seem to be safe for women with completely staged stage I cervical cancer > 2 cm in diameter, whereas even after primary chemoradiation, patients with positive lymph nodes experienced recurrence. Therefore, selection of patients with stage I cervical carcinoma > 2 cm, eligible for fertility preservation should include histopathologic evaluation of lymph node status before any further treatment.     

Sexuality and psychological wellbeing in women with polycystic ovary syndrome compared with healthy controls

Objectives

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of fertile age. The aim was to study whether PCOS has an effect on sexual functioning.

Study design

Women meeting the Rotterdam criteria for PCOS (n = 49), and 49 age-matched controls identified from the population registry, were recruited. Sexual functioning was assessed by means of (i) an in-person, structured interview covering various aspects of sexuality, and (ii) the nine-item McCoy questionnaire of female sexual satisfaction. Participants also completed the Psychological General Well-Being Index.

Results

Almost half the women with PCOS reported that the disorder had a great impact on their sex life. Despite having the same number of partners and about the same frequency of sexual intercourse, women with PCOS were generally less satisfied with their sex lives compared to the population-based controls. Within the group of women with PCOS, high body mass index had only a minor effect on sexual functioning, while the total serum level of testosterone correlated positively to sexual satisfaction. PCOS women scored numerically lower than controls on the McCoy total score, but this difference was not statistically significant.

Conclusion

Women with PCOS reported decreased satisfaction with their sex life. Sexual function should be taken into account in treatment trials of PCOS, which traditionally target only symptoms related to insulin resistance, overweight, and hirsutism.     

Hot flashes during pregnancy: a comparative study

Objective

To conduct a preliminary study assessing the association of hot flashes with pregnancy.

Study design

268 pregnant and non-pregnant women matched on age and race completed a written questionnaire on sociodemographic and clinical information and the experiences of hot flashes. Binary logistic regressions were used to determine predictors of hot flashes.

Results

While controlling for significant bivariate associations, pregnant women were more likely to report hot flashes than non-pregnant women (odds ratio 5.22; confidence interval 2.75-9.89; p < 0.001). Hot flashes during pregnancy typically first occurred before the third trimester and were experienced on a weekly basis. Most pregnant women reported that their hot flashes were not severe or bothersome.

Conclusions

Findings suggest that hot flashes are common during pregnancy. Studies of hot flashes during pregnancy may further elucidate the causal mechanisms of hot flashes in other populations.     

Outcome of loop electrosurgical excision for HIV-positive women in a low-resource outpatient setting

Objective

To assess outcome in HIV-positive women undergoing the loop electrosurgical excision procedure (LEEP).

Method

A prospective study was conducted with 789 outpatients undergoing LEEP at Chiang Mai University Hospital between October 2004 and June 2008.

Results

The 70 HIV-positive women (8.9%) were younger (P < 0.001) and had a lower parity (P < 0.001) than the remaining women. The proportion of women undergoing LEEP for persistent low-grade lesions was higher (8.6% vs 1.9%) and the prevalence of margin involvement was higher (60.0% vs 49.4%) among the HIV-positive women. After adjusting for age, parity, menopausal status, size of excised lesion, and histopathologic result, HIV infection was not significantly associated with LEEP complications (adjusted odds ratio, 0.41; 95% confidence interval, 0.15-1.15).

Conclusion

The higher risk of resection margin involvement in HIV-infected women was not associated with LEEP complications.