David A. Grainger

12 Hysteroscopic management of uterine bleeding

Summary Hysteroscopy provides a means of accurately diagnosing and treating most forms of abnormal uterine bleeding. Submucous myomas and endometrial polyps may be easily removed with the resectoscope. If the myomas are large, pre-treatment with GnRH agonists will shrink the tumours, and facilitate hysteroscopic removal. One third of patients undergoing hysteroscopic myomectomy will have recurrent symptoms that require intervention. In the absence of malignancy, and in patients not desiring fertility, persistent dysfunctional uterine bleeding may be treated by endometrial ablation. These patients should be pre-treated with either danazol or GnRH agonists. Success with these techniques approaches 85%, but information about the long-term outcome for the majority of the reported cases is not available. Complications include uterine perforation and damage of intra-abdominal structures, fluid and electrolyte imbalance including pulmonary oedema, and anaphylactic reactions to certain distention media (32% dextran 70). These procedures provide the gynaecologist with an effective means of treating abnormal uterine bleeding without the attendant morbidity of a hysterectomy.

Progesterone administration induced impairment of insulin suppression of hepatic glucose production

OBJECTIVEnTo assess whether P administration impairs insulin-mediated glucose uptake.nnnDESIGNnTwo-step euglycemic hyperinsulinemic clamp studies.nnnSETTINGnRats studied with (n = 11) or without (n = 10) P treatment.nnnPARTICIPANTSnConscious, unstressed, oophorectomized female rats.nnnMAIN OUTCOME MEASURESnPlasma glucose and insulin levels and the rates of glucose turnover results.nnnRESULTSnFasting glucose (115 +/- 5 versus 109 +/- 4 mg/dL; conversion factor to SI units 0.05551) and insulin (1.67 +/- 0.24 versus 1.51 +/- 0.22 ng/mL; conversion factor to SI units 174.5) levels were not significantly different in the control and P treated groups, respectively. However, the basal rate of glucose turnover was significantly higher in P-treated rats (8.38 +/- 0.50 versus 6.59 +/- 0.35 mg/kg per minute in controls. During low-dose insulin infusion (2 mU/kg per minute), there was no difference in glucose or insulin levels, or the rate of glucose utilization; however, residual hepatic glucose production was significantly greater in the P group (5.34 +/- 0.68 versus 2.57 +/- 1.00 mg/kg per minute) in controls. At high-dose insulin infusion (10 mU/kg per minute), hepatic glucose production was completely suppressed in both groups; there was no difference in insulin sensitivity as assessed by the glucose utilization rate or the ratio of glucose uptake to insulin level.nnnCONCLUSIONSnChronic P therapy does not alter insulin-mediated glucose utilization in peripheral tissues but does reduce the ability of insulin to suppress endogenous hepatic glucose production.

Counter-regulatory response to hypoglycemia in the follicular and luteal phases of the menstrual cycle * †

OBJECTIVEnTo assess whether the phase of the menstrual cycle influences the counter-regulatory response to hypoglycemia.nnnDESIGNnProspective randomized euglycemia-hypoglycemia clamp studies in the follicular and luteal phases of the menstrual cycle in the same woman.nnnSETTINGSnClinical Research Center, Yale University School of Medicine.nnnPATIENTSnEight regularly menstruating nonobese women.nnnMAIN OUTCOME MEASURESnCounter-regulatory hormonal response to hypoglycemia-epinephrine, norepinephrine, glucagon, cortisol, GH, and PRL; glucose homeostasis: rates of whole-body glucose appearance and utilization, and the rate of hepatic glucose production.nnnRESULTSnIn the follicular and luteal phases of the cycle fasting glucose levels (88 +/- 1 and 85 +/- 2 mg/dL, mean +/- SEM, respectively; conversion factor to SI units, 0.05551), basal glucose turnover (2.37 +/- 0.20 and 2.63 +/- 0.13 mg/kg per minute), basal insulin levels (10 +/- 1 and 9 +/- 1 microU/mL; conversion factor to SI units, 6.0), and insulin levels during the clamp study (53 +/- 3 and 45 +/- 4 microU/mL) were not significantly different. During the euglycemic phase of both studies, glucose utilization rose twofold (to 4.73 +/- 0.31 and 4.39 +/- 0.31 mg/kg per minute): hepatic glucose production was suppressed; and counter-regulatory hormones remained unchanged. Induction of hypoglycemia produced increases in the concentrations of counter-regulatory hormones that were indistinguishable in both phases of the cycle. Similarly, the increase in hepatic glucose production provoked during hypoglycemia was similar in each phase of the cycle (1.20 +/- 0.24 and 1.28 +/- 0.36 mg/kg per minute).nnnCONCLUSIONnThe counter-regulatory hormonal response to hypoglycemia, as well as the metabolic sequelae of these hormonal changes, are similar in the follicular and luteal phases of the menstrual cycle.

Influence of basal androgen levels in euandrogenic women on glucose homeostasis

OBJECTIVEnTo evaluate possible relationships between insulin action and the normal variations of serum androgens in euandrogenic women.nnnDESIGNnProspective evaluation of insulin action in normal nonobese women using hyperglycemic and euglycemic hyperinsulinemic clamp techniques, correlating insulin action to serum testosterone (T), free T, androstenedione (A), and dehydroepiandrosterone sulfate (DHEAS). Statistical analysis used Spearmans rank correlation.nnnSETTINGnYale University Clinical Research Center.nnnPARTICIPANTSnNonobese females with normal oral glucose tolerance tests, on no medications known to affect glucose metabolism, having the following range of serum androgen levels: T, 0.69 to 3.12 nmol/L; free T, 0.17 to 1.25 nmol/L; A, 2.48 to 11.31 nmol/L; DHEAS, 0.68 to 10.61 mumol/L. Total number of patients studied: hyperglycemic clamps, n = 58; euglycemic hyperinsulinemic clamps, n = 43.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnPancreatic insulin secretion in response to hyperglycemia and insulin action as assessed by insulin-mediated glucose utilization using the euglycemic, hyperinsulinemic clamp technique.nnnRESULTSnWe identified no significant correlation between serum androgens and either glucose uptake or insulin-mediated glucose utilization. Glucose-stimulated insulin release was negatively correlated with serum T and free T throughout the normal range of these hormones.nnnCONCLUSIONnWe conclude that, within the normal range, variations of serum androgens are not correlated with changes in the response to insulin. It seems unlikely, therefore, that modest increases of serum androgens within the normal range are responsible for inducing insulin resistance.

Residents as Medical Student Mentors During an Obstetrics and Gynecology Clerkship.

BACKGROUNDnResident physicians provide much of the clinical teaching for medical students during their clerkship rotations, but often receive no formal preparation or structure for teaching and mentoring students.nnnOBJECTIVEnWe sought to evaluate a medical student mentoring program (MSMP) for students during their obstetrics and gynecology clerkship at a midwestern teaching hospital during the 2013-2014 academic year.nnnMETHODSnA senior resident physician was assigned 1 to 2 medical students for a 6-week rotation. Students were provided MSMP information during clerkship orientation; residents were given information on MSMP requirements and were randomly assigned to students. We surveyed students and residents about their experience with the MSMP.nnnRESULTSnOf 49 eligible medical students, 43 (88%) completed postsurveys. All students reported not having a mentoring program on other clerkships. Postclerkship, students indicated that they would participate in the MSMP again (32 of 38, 84%), and felt that having a mentor on other clerkships (30 of 36, 83%) would be beneficial. Students reported receiving educational (20 of 41, 49%) and procedural (33 of 41, 80%) instruction, personal development feedback (23 of 41, 56%), and career advice (14 of 41, 34%) from resident mentors. Out of a total of 45 possible surveys by residents, 17 (38%) were completed. Residents did not feel burdened by students (14 of 17, 82%), and all responded that they would participate in the MSMP again.nnnCONCLUSIONSnFeedback from medical students suggests that a mentoring program during clerkships may provide potential benefits for their careers and in 1-on-1 instruction.

Residents as Medical Student Mentors During the Obstetrics and Gynecology Clerkship

PURPOSE: To establish and evaluate a medical student mentoring program (MSMP) for medical students during their obstetrics and gynecology clerkship. BACKGROUND: Mentoring programs for medical students during core clerkships is novel for some institutions, including the University of Kansas School of Medicine-Wichita. Numerous potential benefits are possible. Identification and neutralization of potential barriers to implementation may lead to long term enthusiasm for and acceptance of the mentoring program. METHODS: One senior obstetrics and gynecology resident physician was assigned one or two medical students per 6-week rotation. Residents were given information regarding MSMP requirements, and randomly assigned to students. Students were provided MSMP information during clerkship orientation. Surveys were administered to students during orientation before meeting their residents and at the end of clerkship. Surveys were administered to residents during the last week of clerkships. RESULTS: Surveys were collected from 29 students. All students reported not having a MSMP available on other clerkships. Postclerkship, students indicated they would participate in the MSMP again (79.3%), felt other students would benefit from having a mentor on other clerkships (75.0%), and felt the MSMP was beneficial to their clerkship (81.5%). Students reported receiving educational (11, 44.0%) and clinical (21, 84.0%) instruction, personal development feedback (14, 56.0%), and career advice (6, 24.0%) from mentors. Mentors returned 16 feedback surveys; residents were not burdened by students (75.0%), and all mentors responded that they would participate in the MSMP again. DISCUSSION: Establishing a mentoring program for medical students during core clerkships is novel for the University of Kansas School of Medicine-Wichita, and may provide potential benefits and one-on-one instruction to medical students.

The Death of the Vaginal Hysterectomy [122]

INTRODUCTION: Owing to advancements in technology, the number of vaginal hysterectomy cases available for resident physician education has changed over the years. This study examined the trend in vaginal hysterectomies and attending physician availability for resident physician instruction. Currently, there is limited research on this topic in regard to residency education. METHODS: After obtaining institutional review board approval, the number of cases for all types of hysterectomies performed at three resident-affiliated surgical centers for each academic year between July 2007 and June 2013 was retrospectively collected. International Classification of Diseases, 9th Revision procedure codes (68.31–68.9) and Current Procedural Terminology codes (58260–58571) affiliated with hysterectomy procedures were utilized to categorize each procedure. All attending physicians were given the choice to opt out of the study. Number of vaginal hysterectomies performed and year of birth were collected for each consenting physician. RESULTS: Over the 6-year period, 84.5% of all hysterectomies and 72.4% of vaginal hysterectomies were performed in one hospital. The percentage of vaginal hysterectomies decreased significantly over the past 6 years (P<.001). The percentage of vaginal hysterectomies performed differed significantly among the three hospitals (P<.001). Of vaginal hysterectomies performed by attendings, 67.6% of cases were performed by five attending physicians. Two of these five physicians are approaching the expected retirement age (65 years). CONCLUSION: Vaginal hysterectomy percentages significantly decreased over the study period, leading to a paucity of cases available for resident education. The availability of educators experienced in the technique of vaginal hysterectomy is concerning for future resident education.