D. Dicker

Endometrial polyps during menopause, characterization and significance

BACKGROUNDnTo characterize postmenopausal women with endometrial polyps and to evaluate their significance.nnnMETHODSnThe study population included all consecutive postmenopausal patients with a diagnosis of endometrial polyp, treated at our center over a two-year period. Demographic, medical and gynecological data were assessed with regard to the endometrial histologic findings.nnnRESULTSnOf the 146 eligible patients, 15 had endometrial hyperplasia (four with atypia); there were no cases of endometrial carcinoma. The 20 patients (13.7%) using hormone replacement therapy had a significantly higher rate of endometrial hyperplasia than non-hormone users (p<0.006). No differences were observed among the endometrial histological categories for any of the presenting symptoms and signs, ultrasonographic findings, or medical histories.nnnCONCLUSIONSnPostmenopausal endometrial polyp is a common, mostly benign entity. However, the relatively high rate of concomitant endometrial hyperplasia, especially in patients receiving hormone replacement therapy, dictates a thorough histological evaluation in all cases.

Preliminary studies on apoptosis in human fetal ovaries

OBJECTIVEnTo evaluate if apoptosis occurs in human germ cells between 19 and 33 gestational weeks (GW).nnnDESIGNnHuman fetal ovaries were obtained from aborted fetuses aged 19-33 GW.nnnSETTINGnRabin Medical Center, a major tertiary care and referral center.nnnPATIENT(S)nTwenty-seven women undergoing pregnancy termination. The abortions were mostly because of fetal anatomical or chromosomal abnormalities.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nMicroscopy studies, terminal deoxynucleotidyl transferase (TdT) assay (TUNEL), and immunocytochemistry for B-cell lymphoma/leukemia-2 (bcl-2).nnnRESULT(S)nTUNEL assay revealed a slight increase in apoptotic oocytes in fetuses from 23 GW, with a peak at 27 GW. Overexpression of bcl-2 was detected in all ovarian components, regardless of fetal age.nnnCONCLUSION(S)nThere seems to be a slight increase in apoptosis in oocytes from 23 GW with a peak at 27 GW. However, it is very unlikely that these low apoptotic rates could be the cause of the extensive germ cell loss throughout human pregnancy. The overexpression of bcl-2 possibly suggests either that this gene is necessary to overcome extensive apoptotic activity or that it is responsible for the low apoptosis rates. However, these results should be considered with caution, since the ovaries were mostly from abnormal fetuses after feticide.

Uterine activity after betamethasone administration for the enhancement of fetal lung maturation

OBJECTIVEnTo assess the effect of steroids administered for the enhancement of fetal lung maturation on uterine activity.nnnDESIGNnA retrospective analysis.nnnSETTINGnHigh-risk Pregnancy Unit, Golda Medical Center, Petah Tikvah, Israel.nnnPATIENTSnFifty-nine courses of betamethasone therapy prescribed for various indications other than premature contractions were studied in 29 pregnant women at 26-34 weeks gestation.nnnMEASUREMENTSnUterine activity was monitored on the day of the first (but prior to) beta-methasone injection, then daily for the next 3 consecutive days. The number of uterine contractions during the first 30 min of each tocodynamometric tracing was assessed.nnnRESULTSnThe frequency of uterine activity after steroid administration is significantly higher in multiple pregnancies as compared to singletons, and significantly increases as the duration of pregnancy increases. However, labor was not induced and all women delivered at least 1 week after the last betamethasone injection.nnnCONCLUSIONSnSince the increased uterine activity after administration of steroids for the enhancement of fetal lung maturation does not provoke labor, it is suggested that this increase in uterine activity seems to act as a temporary phenomenon. Therefore conservative management, rather than tocolysis, would seem appropriate.

Hyperemesis gravidarum during Ramadan

During Ramadan, adult Muslims fast from dawn to dusk. We frequently encounter young pregnant Muslim women with hyperemesis gravidarum who fast during this holy month. We have investigated whether there is an association between the prolonged fasting during Ramadan and excessive vomiting during pregnancy. Possible psychologic and physiologic explanations are presented and discussed.

Modified hysterosalpingography during infertility work-up: use of contrast medium and saline to investigate mechanical factors

OBJECTIVEnTo evaluate the effectiveness of modified hysterosalpingography using <3 mL amount of contrast medium followed by injection of saline to minimize the adverse effects associated with the procedure.nnnDESIGNnFor modified hysterosalpingography, 1-2 mL of water-soluble contrast medium were injected to visualize the uterine cavity, followed by injection of 10 mL of saline to check tubal patency and spillage. A control group of patients underwent hysterosalpingography with undiluted contrast medium.nnnSETTINGnTeaching hospital.nnnPATIENT(S)nSeventy-eight infertile women [study (n = 40)/control (n = 38) groups].nnnINTERVENTION(S)nModified and standard hysterosalpingography.nnnMAIN OUTCOME MEASURE(S)nAssessment of uterine cavity, tubal patency, and sensation of pain during modified hysterosalpingography was compared with that during standard hysterosalpingography.nnnRESULT(S)nUterine cavity and tubal patency were properly visualized during modified hysterosalpingography. Saline pushed the contrast medium successfully from the uterine cavity through the open fallopian tubes and into the pelvic cavity. The study group reported significantly less pain than did the control group. Between-group differences were statistically significant when pain perception (no pain vs. minimal pain vs. severe pain; no pain vs. any kind of pain) was analyzed by type of adnexal pathology (bilateral passage or unilateral passage).nnnCONCLUSION(S)nModified hysterosalpingography was sufficient to diagnose tubal and pelvic mechanical factors. The procedure was associated with a significant reduction in self-reported pain and no medical complications.

Laparoscopic management of suspicious ovarian cysts in elderly, postmenopausal women

OBJECTIVESnTo present our experience with laparoscopic treatment of ovarian cysts in elderly, postmenopausal women.nnnSTUDY DESIGNnDuring the period January 1996 to August 1997, 21 elderly, postmenopausal women were admitted to the Rabin Medical Center for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, was larger than 4 cm, had pathological Doppler flow or elevated CA-125 level.nnnRESULTSnThe median age of the patients was 67.19 (range 60-74). Despite the fact that 15 (71.4%) of the patients suffered from chronic disease, all laparoscopies were successfully accomplished. No case of malignancy was found.nnnCONCLUSIONSnLaparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases.

Flexible starting schedule for oral contraception: effect on the incidence of breakthrough bleeding and compliance

OBJECTIVEnTo compare the effect of starting oral contraceptives on the first day of menses with the effect of starting on the day of menses cessation (but no later than the 5th day following its onset), on the incidence of early breakthrough bleeding.nnnMETHODnOral contraceptives containing 30 micrograms ethinylestradiol and 75 micrograms gestodene were prescribed to 200 consecutive healthy women in whom oral contraceptives were found to be the most suitable method of contraception. In the first 100 women, treatment was started on the 1st day after the onset of menses (Day 1 group), and in the remainder, treatment was started on the day of menses cessation, but no later than the 5th day following its onset (Flexible group).nnnRESULTSnThe Flexible group had better compliance and a reduced incidence of breakthrough bleeding. No differences were observed between the two groups for age, parity and gravity, or contraceptive failure.nnnCONCLUSIONSnOral contraceptives may be initiated on the day of menses cessation, but no later than the 5th day following its onset. This regimen might increase patient compliance and lower the incidence of breakthrough bleeding, probably without adversely affecting contraceptive efficacy.

A delayed starting schedule of oral contraception: The effect on the incidence of breakthrough bleeding and compliance in women

OBJECTIVESnTo assess the effect of oral contraception started on the first day of menses and the fifth day following its onset, on womens compliance and the incidence of early breakthrough bleeding.nnnMETHODSnOral contraceptives (OCs) containing 30 micrograms ethinylestradiol and 75 micrograms gestodene were prescribed to 100 consecutive, healthy women for whom OCs were found to be the most suitable method of contraception. In the first 50 women, OCs were started on the first day of menses (day 1 group), while in the remaining 50 women, OCs were started on the fifth day after the onset of menses (day 5 group).nnnRESULTSnThe day 5 group had better compliance and a reduced incidence of breakthrough bleeding. No differences were observed between the two groups regarding age, parity and gravity.nnnCONCLUSIONnStarting an OC regimen should include initiation on the fifth day following the onset of menses. This regimen might increase patient compliance and lower the incidence of breakthrough bleeding.

Emergency hysteroscopic treatment of acute severe uterine bleeding

The aim of this pilot feasibility study was to investigate the efficacy and safety of hysteroscopy in the diagnosis and treatment of acute severe uterine bleeding. Forty-one women (mean age, 54 years) who underwent emergency hysteroscopy were assessed. In 40 women, a benign organic cause was found. In one postmenopausal patient, endometrial carcinoma was detected in endometrial chips and was managed with hysterectomy. None of the women with benign lesions required further surgery within the first postoperative year. One underwent hysterectomy at 18 months for new-onset fibromyomas. Hysteroscopy was found to be an effective tool for treating heavy uterine bleeding. It also prevented future episodes of severe bleeding in more than half the patients during 20 months of follow-up.

Treatment of the twisted cystic ovary with normal blood flow by simple aspiration

Simple aspiration was performed in eight patients to correct torsion of cystic ovaries with normal blood flow, imaged by the colour Doppler technique. Abdominal pain resolved spontaneously following aspiration. Symptoms recurred in three patients, necessitating detorsion by laparoscopy. Normal follicular growth was assessed within 3 months in the non-pregnant patients.Simple aspiration was performed in eight patients to correct torsion of cystic ovaries with normal blood flow, imaged by the colour Doppler technique. Abdominal pain resolved spontaneously following aspiration. Symptoms recurred in three patients, necessitating detorsion by laparoscopy. Normal follicular growth was assessed within 3 months in the non-pregnant patients.