The influence of a low-dose combined oral contraceptive on menstrual blood loss and iron status.

The influence of a low-dose combined oral contraceptive (ethinyl estradiol 30 micrograms + desogestrel 0.15 mg) on menstrual blood loss (MBL) was evaluated in 20 healthy, young women. MBL prior to commencing oral contraception was 60.2 +/- 5.6 ml (range 22-116 ml), and decreased (p < 0.001) to 36.5 +/- 5.2 ml (range 7-80 ml) and 33.7 +/- 4.1 ml (range 5-70 ml) after 3 and 6 months' oral contraceptive medication, respectively. The reduction in MBL during oral contraception was most apparent during the first two days of menstruation. Five women had an MBL > 80 ml prior to commencing oral contraceptive medication. In all of these women, MBL during the 6th menstrual period after commencing oral contraception was < 80 ml. All the women included in this study had a normal blood hemoglobin concentration, hematocrit and erythrocyte indices and there were no significant changes in these variables during the course of the study. Serum ferritin concentration prior to commencing oral contraception was 44.2 +/- 9.0 micrograms/l and was largely unchanged after 6 months' oral contraception (39.7 +/- 6.3 micrograms/l). On admission to the study, two women had a serum ferritin < 10 micrograms/l, indicative of low iron stores. Both these women had an MBL > 80 ml at the baseline assessment. Serum ferritin concentration increased during oral contraceptive medication in both women (from 8.5 micrograms/l to 12.0 micrograms/l and from 5.4 micrograms/l to 6.8 micrograms/l, respectively). The duration of menstruation (p < 0.01) and the number of women suffering from dysmenorrhea (p < 0.05) was reduced during oral contraception.     

Is colonoscopic screening appropriate in asymptomatic patients with family history of colon cancer?

Colonoscopy has been advocated by some investigators as the most appropriate means of screening asymptomatic patients with a positive family history of colorectal cancer. However, results of such screening have been widely disparate. The purpose of this study was to evaluate the yield of colonoscopy in a cohort of completely asymptomatic individuals with one or two first-degree relatives with a history of colorectal cancer and to compare this yield with that of colonoscopy in a group of patients with apparent anal bleeding. Patients with possible genetic disorders, such as familial polyposis, were excluded. A total of 160 asymptomatic patients and a comparison group of 137 patients with nonacute anorectal bleeding underwent colonoscopy. Colonoscopy was completed in 143 of the 160 study patients (89 percent) and in all of the comparison patients and did not result in any complications. Twenty-two adenomas were found in 17 study patients (10.6 percent); 16 of the 22 adenomas were less than 1 cm in size. In the comparison group, eight adenomas were identified (5.8 percent of patients). No cancers were identified. The difference in polyp frequency between groups was not significant. The relatively low yield of colorectal neoplasms discovered at colonoscopy in this study may in part be due to the small sample size or to the strict criteria used to define these asymptomatic patients but does not lend strong support to the notion that colonoscopy is an appropriate first step in screening the asymptomatic patient with one or two first-degree relatives with colon cancer.     

A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia

Treatment with flurbiprofen (100 mg twice a day for 5 days), tranexamic acid (1.5 gm three times a day for 3 days and 1 gm twice a day for another 2 days), and an intrauterine contraceptive device releasing 20 micrograms levonorgestrel per day was compared in women with idiopathic menorrhagia. The menstrual blood loss during two control periods in 15 women subsequently treated with flurbiprofen and tranexamic acid was 295 +/- 52 ml and 203 +/- 25.2 ml in the 16 women later fitted with a levonorgestrel-releasing intrauterine contraceptive device. Menstrual blood loss was reduced by all three forms of treatment. The reduction in menstrual blood loss expressed as a percentage of the mean of two control cycles for each form of treatment was as follows: flurbiprofen, 20.7% +/- 9.9%; tranexamic acid, 44.4% +/- 8.3%; levonorgestrel-releasing intrauterine contraceptive device after 3 months, 81.6% +/- 4.5%; levonorgestrel-releasing intrauterine contraceptive device after 6 months, 88.0% +/- 3.1%; levonorgestrel-releasing intrauterine contraceptive device after 12 months, 95.8% +/- 1.2%. The reduction in menstrual blood loss achieved by the levonorgestrel-releasing intrauterine contraceptive device was greater than that recorded with flurbiprofen (p less than 0.001) and tranexamic acid (p less than 0.01), and was greater for tranexamic acid when compared with flurbiprofen (p less than 0.05). The levonorgestrel-releasing intrauterine contraceptive device was the only form of treatment to reduce mean menstrual blood loss below 80 ml per menstruation, the upper limit of normal menstrual blood loss.     

Colorectal anastomotic stenosis results of a survey of the ASCRS membership

Anastomotic stenosis is a poorly understood and underexamined complication of gastrointestinal surgery, reportedly most frequent in the coloproctostomy. In order to better define this problem, a questionnaire was sent to members of the American Society of Colon and Rectal Surgeons regarding patients with gastrointestinal anastomotic stenosis. A total of 123 patients with intestinal anastomotic stenosis were analyzed. Eighty-two anastomoses were stapled and 41 were handsewn. Nearly all stenoses occurred in the distal bowel (70 rectal, 23 sigmoid colon). Preoperative risk factors identified were obesity (28 patients) and abscess (12 patients). Incomplete “doughnuts” were noted in 12 patients. Postoperative anastomotic leaks (15 patients), pelvic infection (13 patients), and postoperative radiation (7 patients) were believed to be contributing factors. Dilatation, using a variety of techniques, was the sole treatment for 65 patients, however, intra-abdominal surgery was necessary in 34 patients. Large intestinal anastomotic stenosis probably occurs most commonly following coloproctostomy (both with handsewn and stapled anastomoses). Dilatation alone resulted in adequate treatment in most patients in the study. Major surgery was required to correct this problem in a significant number of patients (28 percent) in this series. The true incidence of anastomotic stenosis in colorectal surgery is unknown and warrants further study. Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

Maculopapular eruption with enlarged macrophages in eight patients receiving G-CSF or GM-CSF

In the last years, granulocyte and granulocyte-macrophage colony-stimulating factors (G-CSF and GM-CSF) are being increasingly used and several cutaneous eruptions have been reported in relation to these treatments. In 1991 Horn et al. described three patients with maculopapular eruption that paralleled the time of infusion of GM-CSF. Two of the cases showed an increase in the number and size of macrophages in the biopsy specimen. Since then, several cases have been reported showing this histopathological alteration that has been considered characteristic of reaction to G-CSF or GM-CSF. Although maculopapular eruption with enlarged macrophages can appear after chemotherapy treatment, we have found that the presentation of this eruption after the beginning of cytokine treatment is suggestive of the involvement of G-CSF and GM-CSF in the eruption. We described eight cases of patients treated with G-CSF or GM-CSF that developed maculopapular eruptions with enlarged macrophages.     

Quantification of naturally occurring benzodiazepine-like substances in human breast milk

The possible occurrence of benzodiazepine-like substances in human breast milk was investigated in 35 healthy, newly delivered women who were known not to be taking benzodiazepines. Maternal blood samples and a sample of breast milk were obtained on the fifth post partum day. A radioreceptor technique (lower limit of detection 1.5 ng/ml; difference between duplicates at various concentrations <7%) was used for measuring benzodiazepine-like substances in blood and breast milk (with and without prior extraction). No benzodiazepine-like substances could be demonstrated in any of the blood samples taken from the 35 women. Measurable concentrations of benzodiazepine-like substances were demonstrated in all but 1 of the 35 breast milk samples. The mean concentration of benzodiazepine-like substances for all 35 women was 4.3±2.3 ng/ml (range 0–9.3 ng/ml) expressed as lorazepam. The corresponding value for extracted breast milk was 2.6±1.5 ng/ml (range 0–7.0 ng/ml). There was no association between concentrations of benzodiazepine-like substances in breast milk and maternal age, weight, height and body mass or parity, or the sex of the infant and infant birth weight. We suggest that non-detectable amounts of benzodiazepine-like substances in serum are concentrated in the mammillary glands and excreted in a higher concentration in breast milk. It is less likely that the relevant benzodiazepines are produced in the mammillary glands.     

A longitudinal population study of climacteric symptoms and their treatment in a random sample of Swedish women.

OBJECTIVES: To assess, first, the prevalence and severity of symptoms associated with the climacteric period and their treatment and, second, the prevalence of exercise, smoking and body weight in a population-based sample of Swedish women. MATERIAL AND METHODS: Prospective, longitudinal cohort study, initiated in 1992, in women aged 46, 50, 54, 58 and 62 years with a follow-up 6 years later. Information was obtained from the same women (n=3816) on both occasions using a postal questionnaire regarding sociodemographic variables, general and reproductive health, the occurrence of climacteric symptoms and their severity, and the use of hormone replacement therapy (HRT). RESULTS: The prevalences of climacteric symptoms were as follows (1992/1998): vasomotor symptoms, 52%/62%; depression/irritability, 57%/65%; sleeping disturbances, 51%/69%; muscle/joint pain, 55%/70%; and loss of libido, 38%/57%. HRT with medium-potency estrogens was currently being used by 34% (1992: 14%), and 12% (1992: 8%) were using low-potency estrogens. The maximum prevalence of HRT (medium-potency estrogens) use was found in the 56-year-old group, at 46% (1992: 25% in the 54-year-old group). Body mass for the whole group had increased from 66.3 to 68.9 kg. Exercise was more frequent in all age groups in 1998 compared to 1992. There was a decrease in current smokers from 32 to 26% between the two periods. Compared with 1992, the women in all five birth cohorts considered themselves to be less healthy and quality of life had decreased for the whole group. CONCLUSIONS: The prevalence of symptoms associated with the climacteric period and the use of HRT had increased markedly in this longitudinal study of the same women followed between 1992 and 1998. During the same period, smoking decreased, while body weight and exercise frequency increased.     

Perioperative tumor localization for laparoscopic colorectal surgery

Background: Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken. Method: A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness. Results: In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)—tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)—poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)—no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected. Conclusions: Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy ± suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted. Received: 18 July 1996/Accepted: 10 March 1997