Dyspareunia; surgery or low dose progestin both are effective

Medscape Medical News

Dyspareunia: Surgery and Low-Dose Progestin Both Effective

Joe Barber Jr, PhD

Apr 17, 2013

Editors' Recommendations

• 
  FDA OKs Drug for Postmenopausal Dyspareunia
• Surgical Treatment of Endometriosis: Excision and Ablation Both Relieve Pain
• MPA Therapy Appears Effective in Alleviating Endometriosis Pain

Drug & Reference Information

• Malposition of the Uterus
• Fallopian Tube Reconstruction
• Benign Lesions of the Ovaries

Surgery and low-dose progestin are similarly effective against endometriosis-associated severe deep dyspareunia, but the timing of their effects differs, according to the findings of a patient-preference, parallel cohort study.

Paolo Vercellini, MD, from Università Statale di Milano and the Fondazione IRCCS 'Ca' Grandà–Ospedale Maggiore Policlinico in Milan, Italy, and colleagues present their findings in an articlepublished online February 26 and in the May issue of Human Reproduction.

"Painful sex also has personal and intimate implications, including substantial psychological and relational distress, as well as unfavourable emotional impact in partners," the authors write. "However, only limited information is available on the consequences of endometriosis-associated deep dyspareunia, as well as of the effect of medical and surgical treatment alternatives for this condition, in terms of variations in sexual functioning, psychological status and health-related quality of life."

Therefore, the authors recruited 18- to 40-year-old nonpregnant women who had previously undergone laparoscopy or laparotomy for stage 3/4 endometriosis in the previous 2 years and allowed them to select surgical or low-dose norethisterone acetate (NETA) treatment.

Among 51 women who underwent surgery and 103 women who selected NETA treatment, higher Female Sexual Function Index overall scores and subdomain scores were noted in the surgery group after 3 months, but the differences dissipated by 12 months, excluding the higher scores for lubrication, desire, and arousal in the surgery group.

However, significant differences from baseline were observed in the overall scores in both the surgery (P< .0001) and NETA (P = .002) groups.

The exclusion criteria included obstructive uropathy or bowel stenosis, typical contraindications to progestins, and an unwillingness to tolerate menstrual changes; the authors performed regression analysis adjusted for age, sex, body mass index, and other variables.

Similar to what was observed for Female Sexual Function Index scores, the Hospital Anxiety Depression Scale overall and subdomain scores were higher in the surgery group after 3 months, but these differences did not persist at 12 months. The overall and subdomain Hospital Anxiety Depression Scale scores were significantly lower after 12 months compared with baseline in both groups (P ≤ .0001).

For the Endometrial Health Profile-30 scores, the NETA group had significantly (P < .05) worse scores for the subdomains of pain, control and powerlessness, and medical profession. The surgery group had significantly higher Endometrial Health Profile-30 scores for the subdomains of emotional well-being, social support, self image, sexual intercourse, and infertility at 3 months, whereas significant differences in favor of the NETA group were observed for pain, control and powerlessness, relationship with children, work, and medical profession at 12 months.

The limitations of the study included a lack of randomization, selection bias, and an imbalance in the study groups.

"In conclusion, surgery and low-dose oral NETA demonstrated a similar final beneficial outcome in women with endometriosis-associated deep dyspareunia in terms of improvement of sexual functioning, psychological well-being and health-related quality of life at 1-year follow-up," the authors write. "[I]n light of the observed differences in the temporal pattern of the effect, further comparative studies with longer follow-up are warranted."

The study was supported by a research grant from the University of Milan School of Medicine. The authors have disclosed no relevant financial relationships.

Hum Reprod. 2013;28:1221-1230. Abstract

From Reuters Health Information CME

Ectopic Pregnancy Treatments Have Similar Fertility Impact 

News Author: David Douglas
CME Author: Laurie Barclay, MD

 

Faculty and Disclosures

CME Released: 04/09/2013; Valid for credit through 04/09/2014

CLINICAL CONTEXT

To date, radical and conservative surgical treatments of ectopic pregnancy have not been compared in a randomized trial. Data were insufficient in a recent Cochrane review to draw conclusions regarding fertility after these treatments. However, fertility is similar after medical treatment and conservative surgery and is lower after radical surgery, based on prospective studies from ectopic pregnancy registries in 2 regions of France.

The objective of this study by Capmas and colleagues was to determine if treatment for the resolution of ectopic pregnancy affects subsequent spontaneous fertility with occurrence of an intrauterine pregnancy.

STUDY SYNOPSIS AND PERSPECTIVE

In women with ectopic pregnancy, both surgical and medical management have a comparable effect on later spontaneous fertility, according to French researchers reporting on the DEMETER trial.

"On one hand, for active ectopic pregnancy that requires surgical management, women can be reassured about their subsequent fertility even if a radical treatment is necessary as there is no difference between subsequent fertility after conservative or radical surgery," Dr. Perrine Capmas told Reuters Health by email.

"On the other hand," she added, "for less active pregnancy, women's preference is often medical treatment as there is no anesthesia and no surgery. However, as monitoring after medical treatment may sometimes be long, for some less observant women, conservative surgery should be offered as first-line."

In a March 12th online paper in Human Reproduction, Dr. Capmas of Hôpital Bicêtre, University Paris-Sud, and colleagues observe that improved diagnostic methods such as ultrasonography have made it possible to identify ectopic pregnancies earlier and more accurately, reducing serious adverse events.

Nevertheless, published data on fertility after various types of treatment is mainly observational. To gain further information, the researchers studied 406 women with ultrasound-confirmed ectopic pregnancy who were managed with either methotrexate injection to interrupt pregnancy in the Fallopian tube; conservative surgery (salpingostomy, which preserves the Fallopian tube); or radical surgery (salpingectomy).

The 207 women with a less active pregnancy (based on factors including Fernandez's score of less than 13 and no hemodynamic failure) were randomly assigned to receive conservative surgery followed by IM methotrexate or IM methotrexate alone.

In the remaining 199 women with active pregnancy, medical treatment was considered impractical because of clinical suspicion of rupture or a high Fernandez's score. These patients were randomized to conservative surgery followed by methotrexate or to radical surgery.

Two years later, rates of spontaneous intrauterine pregnancy in the less active pregnancy group were similar in those who had medical treatment, at 67%, and those who had conservative surgery, at 71%.

In the active pregnancy group, the rates were 70% after conservative surgery and 64% after radical surgery – again, not a significant difference.

Normal pregnancy rates in the general population in women who have not had an ectopic pregnancy range from about 84% to 89%.

Although the trial was conducted at 17 centers and sample sizes were small for some of them, the researchers say "the multicenter nature of the study provided a good external validity and, thus, a high level of evidence."

In particular, Dr. Capmas said in a statement, "If a woman has an active ectopic pregnancy for which surgery is the only treatment possible, then we can tell them that even if we try conservative surgery first, there is a risk they will need more radical surgery. However, we can tell them that subsequent fertility seems to be similar after each treatment."

Hum Reprod. Published online March 12, 2013.

STUDY HIGHLIGHTS

From Reuters Health Information CME

Maternal Viral Load Key to Neonatal HBV Infection 

News Author: Megan Brooks
CME Author: Laurie Barclay, MD

 

Faculty and Disclosures

CME Released: 03/29/2013; Valid for credit through 03/29/2014

CLINICAL CONTEXT

Worldwide, hepatitis B virus (HBV) infection is a major cause of morbidity including liver cirrhosis and hepatocellular carcinoma. Although immunoprophylaxis with vaccination lowers rates of HBV transmission, it does not completely eradicate infection. In highly endemic regions, HBV infection is usually acquired perinatally or in early childhood, often resulting in chronic disease and complications.

The goals of this prospective study by Dr. Huey-Ling Chen and colleagues were to determine the rate and risk factors of maternally transmitted HBV infection.

STUDY SYNOPSIS AND PERSPECTIVE

High maternal viral load is the most important factor causing maternally transmitted hepatitis B virus (HBV) infection and is significantly correlated with e antigen (HBeAg) positivity, according to a prospective study from Taiwan.

"Additional interventions should be considered in these mothers," Dr. Huey-Ling Chen from the Hepatitis Research Center, Hospital and College of Medicine, National Taiwan University in Taipei and colleagues conclude in a report online now in the Journal of Hepatology.

They say their data also provide "important information for the rational design of future screening and intervention strategies to further reduce maternally transmitted HBV infection."

Despite effective immunoprophylaxis, breakthrough HBV infection does occur and may result in mother-to-infant transmission. Transmission from highly viremic mothers remains a major challenge in eradicating HBV-related diseases, the investigators say.

Some studies have suggested that antiviral therapy in highly viremic HBV-infected pregnant women can reduce maternal viral load and transmission risk. Yet the optimal cutoff level of maternal viral load for antiviral therapy in pregnancy remains a topic of debate, they note.

Dr. Chen's team designed their prospective study to assess the rate and risk factors for maternally transmitted HBV infection despite immunoprophylaxis.

Mothers who were positive for hepatitis B surface antigen (HBsAg) were invited to join the study at the time of prenatal visits or delivery. All were HIV-negative. Maternal viral load was determined by a real-time PCR-based assay. Children were tested for HBsAg between four and eight months and/or one to three years of age. The study included a total of 303 mother-infant pairs.

The researchers report that 81 mothers (26.7%) were HBeAg-positive; all of their infants as well as most infants with HBeAg-negative mothers received hepatitis B immune globulin.

HBeAg-positive mothers had significantly higher viral loads than HBeAg-negative mothers (7.4 vs 2.7 log₁₀ copies/mL, p<0 .0001="" span="">

The 10 children born to HBeAg-positive mothers with high viral load (median, 8.4 log₁₀ copies/mL) were chronically infected.

Maternal viral load was significantly associated with risk of infection in analyses adjusted for maternal age, birth type, factors related to maternal-fetal hemorrhage, gestational age, infant gender, birth weight, timeliness of vaccination, and feeding practice. The adjusted odds ratio for each log₁₀ copy/mL increase was 3.49 (95% CI 1.63 to 7.48; p=0.001).

High maternal viral load was "the most important factor in maternally transmitted HBV," the investigators say. The rate of neonatal infection at maternal viral load 7 log₁₀ copies/mL was 6.6%, and jumped to 14.6% and 27.7% at 8 and 9 log₁₀ copies/mL, respectively.

The investigators think additional strategies to further reduce mother-to-child transmission should be considered in mothers with a viral load above 7-8 log₁₀ copies/mL.

While there is no consensus on the optimal cutoff value of maternal viral load for antiviral treatment, the investigators say their findings support antiviral therapy to reduce transmission in HBV-infected pregnant women with a viral load above 7 log₁₀ copies/mL -- and especially in those with a viral load above 8 log₁₀ copies/mL.

Dr. Chen and colleagues emphasize, however, that the advantages of antiviral therapy need to be balanced against the risks. "Although current reports show no significant increase in birth defects and pregnancy complications," they say, "more long-term safety data of antiviral therapy, continued epidemiological surveillance on HBsAg-positive mothers and their children, and cost-effectiveness analyses are needed to develop a safe and cost-effective preventive intervention strategy."

Dr. Chen did not respond to request for comment.

Dr. Ameeta Singh, clinical professor in the division of infectious diseases at the University of Alberta, Edmonton, who reviewed the study for Reuters Health, said the findings are "definitely significant and support previous similar reports from the published literature. They also report increasing rates of transmission at increasing levels of viral load which makes sense but it is always helpful information to both patients and providers when deciding on treatment."

Dr. Singh also noted that the exact viral load cut-off at which treatment should be offered is unclear "and varies between specialists."

"Very few places," she added, "offer routine services and recommend referral to a specialist of all HBsAg infected mothers during pregnancy -- many providers are either not aware that anything other than routine immunoprophylaxis can be offered in some situations. In response to similar work that we undertook a few years ago, the province of Alberta has made some changes to provincial programming to encourage providers to refer all HBsAg infected mothers to specialists."

"I think raising awareness among clinicians -- particularly primary care providers and OBGYN -- that more can be done to reduce mother-to-child HBV in certain situations would be a good thing," Dr. Singh concluded.

The study was funded by the Center for Disease Control, Department of Health, Taiwan. The authors and Dr. Singh have disclosed no relevant financial relationships.

J Hepatol. Published online February 28, 2013.

Simple classification of genital prolapse

Most clinicians routinely use the ICS classification (POP-Q) system, which is classified as follows:

• Stage 0 - No prolapse
• Stage I - Descent of the most distal portion of prolapse is more than 1 cm above the level of the hymen.
• Stage II - Maximal descent of prolapse is between 1 cm above and 1 cm below the hymen.
• Stage III - Prolapse extends more than 1 cm beyond the hymen, but no more than within 2 cm of the total vaginal length.
• Stage IV - Total or complete vaginal eversion
  
  
  ICS= international Continence Society
  
  

Cervicitis specific drug treatment, update

Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for cervicitis are provided below, including those for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis.^{[1, 2, 3, 4, 5]}

Neisseria gonorrhoeae (gonococcal cervicitis)

• Ceftriaxone 250 mg IM in a single dose
• plus
• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

If ceftriaxone is not available:

• Cefixime 400 mg PO in a single dose plus
• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days plus
• Test-of-cure in 1 week

If patient has severe cephalosporin allergy:

• Azithromycin 2 g PO in a single dose plus
• Test-of-cure in 1 week

Chlamydia trachomatis

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days or
• Erythromycin base 500 mg PO QID for 7 days or
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days or
• Ofloxacin 300 mg PO BID for 7 days or
• Levofloxacin 500 mg PO once daily for 7 days

Mycoplasma genitalium

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

Trichomonas vaginalis

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

Organism-specific therapeutic regimens for cervicitis are provided below, including those for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis.^{[1, 2, 3, 4, 5]}

Neisseria gonorrhoeae (gonococcal cervicitis)

• Ceftriaxone 250 mg IM in a single dose plus
• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

If ceftriaxone is not available:

• Cefixime 400 mg PO in a single dose plus
• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days plus
• Test-of-cure in 1 week

If patient has severe cephalosporin allergy:

• Azithromycin 2 g PO in a single dose plus
• Test-of-cure in 1 week

Chlamydia trachomatis

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days or
• Erythromycin base 500 mg PO QID for 7 days or
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days or
• Ofloxacin 300 mg PO BID for 7 days or
• Levofloxacin 500 mg PO once daily for 7 days

Mycoplasma genitalium

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

Trichomonas vaginalis

• Azithromycin 1 g PO in a single dose or
• Doxycycline 100 mg PO BID for 7 days

References

A model for the clinical round examination

Station ( 1   )

Obstetrics: case (1)

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Take the Obstetric history from the patient  (3 marks) 

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Fundal level =………..weeks gestation​(2marks)

 Station (  2  )

Obstetrics: Q (1) :

MENTION :

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THREE complications of DM on the mother       (3) 

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Two complications of DM on the fetus​​​​​​​​

UStation (  3    )

Obstetrics: Case (2)

-

Estimate :

1-

Expected date of delivery  (EDD)   (1)

2-

The gestational age (GA) today        (1)

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Mention 3 prerequisites for trial of cesarean scar  (3)

Station ( 4   )

Obstetrics : ( Q 2 )

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Classification of hypertensive disorder with pregnancy (PIH)                                (3)

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Mention 2 complications of accidental hemorrhage                      (2)

Station (5)

Obstetrics : case (3) :

Identify :

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Fetal lie                                      (1)

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Fetal presentation                       (2)

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Fetal position                             (2)

Station  (6)

Obstetrics :  (Q4)

Mention 5 causes of uterus larger than period of amenorrhea                                               (5)

Station (7)

Gynecology (1)

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Mention the complaint of the patient ​(1 mark)

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Take the menstrual history​                (2 marks)

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Mention 2 indications of recto-vaginalexaminaion​                                 ​(2 marks)

Station (8)

Gynecology (Q4):

Differential diagnosis of mass in Douglas' pouch

Station (9)

Gynecology :

.

Remark the clinical type of genital bleeding (1 )

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Enumerate 2 important investigations that help in the diagnosis of such case (2)

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What is the most serious cause of postmenopausal bleeding (1)

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What is the most common cause of postmenopausal bleeding  (1)

Empty Station

 

​

Station (10)

Gynecology :                    

Mention 5 characters of normal uterus     (5)

Station ( 11   )

Gynecology :

1-

Type & duration of infertility  (2)

2-

List 3 basic investigation for infertile couples (3)

Station ( 12  )

gynecology :

MENTION 3 DIFFERENCES BETWEEN UTERINE & OVARIAN SWELLING

Station (  13  )

SKILL LAB.

1-

Type of operation       (1)

2-

Two indications           (2)

3-

Two complications      (3)

Station ( 14  )

Jar (1)

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Identify the pathology                               (1mark)

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Mention two  symptoms                                      (2marks)

.

Mention two surgical methods of treatment ( 2 marks)                  

Station (15)

JARS (2)

1-

Identify the pathology      (1)

2-

Three methods of early detection  (3)

3-

Most common pre-disposing factor  (1)

Station ( 16  )

Instruments:

1-

Identify the instrument.

2-

Mention 2 indications

3-

Mention 2 complication

Station (17)

Instrument :

1- Identify the instrument  (1)

2- List 2 types of vaginal specula  (2)

3- two indications                            (2) Station (18)

Instrument

.

IDENTIFY THE INSTRUMENT                      (1)

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MAXIMUM NEGATIVE PRESSUREIS………  (1)

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THE VALUE OF THE KNOB IS …………….(1)

.

MENTION 2 COMPLICATIONS…………….(2)