Gamal H. Sayed

A randomized clinical trial of a levonorgestrel-releasing intrauterine system and a low-dose combined oral contraceptive for fibroid-related menorrhagia.

To compare the efficacy of a levonorgestrel‐releasing intrauterine system (LNG‐IUS) with that of a low‐dose combined oral contraceptive (COC) in reducing fibroid‐related menorrhagia.

Levonorgestrel-releasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: a randomized clinical trial

BACKGROUND This study compared the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS) to low dose combined oral contraceptive pills (COC) in the management of idiopathic menorrhagia. STUDY DESIGN A single-center, open, randomized clinical trial. One hundred twelve women complaining of excessive menstruation who desired contraception were randomized to receive LNG-IUS or COC. Treatment failure was defined as the need for medical or surgical treatment during the follow-up. Other outcomes included: menstrual blood loss (MBL) by alkaline hematin and by pictorial blood assessment chart (PBLAC), hemoglobin levels and assessment of lost days in which physical or mental health prevented participating women from performing usual activities. RESULTS At baseline, LNG-IUS (n=56) and COC (n=56) groups were comparable in age (mean ± S.D.) (39.3 ± 6.7 vs. 38.7 ± 5.2 years, p=.637), parity (median and range) [3(1-6.4) vs.3(2-6), p=.802] and BMI (mean ± S.D.) (29.6 ± 5.9 vs. 31.1 ± 5.7 kg/m(2), p=.175). Time to treatment failure was longer in LNG compared to COC group with a total of 6 (11%) patients who had treatment failure in the LNG-IUS compared to 18 (32%) in COC group with a hazard ratio of 0.30 (95% CI, 0.15-0.73, p=.007). Using alkaline hematin, the reduction in MBL (mean ± S.D.) was significantly more in the LNG-IUS group (87.4 ± 11.3%) compared to the COC group (34.9 ± 76.9%) (p=.013). Utilizing PBLAC scores, the reduction in the LNG-IUS (86.6 ± 17.0%) group was significantly more compared to the COC group (2.5 ± 93.2%) (p<.001). In the LNG-IUS group, increase in the hemoglobin and ferritin levels (mean ± S.D.) were noted (from 10.2 ± 1.3 to 11.4 ± 1.0 g/dL; p<.001; with reduction of the number of lost days (from 6.8 ± 2.6 to 1.6 ± 2.4 days, p=.003). CONCLUSION The LNG-IUS is a more effective therapy for idiopathic menorrhagia compared to COC.

Pictorial blood loss assessment chart in the evaluation of heavy menstrual bleeding: diagnostic accuracy compared to alkaline hematin.

Background/Aims: The pictorial blood assessment chart (PBAC) is a method for evaluation of menstrual blood loss (MBL). This study was conducted to evaluate the accuracy of the PBAC score in diagnosing MBL compared to alkaline hematin as a gold standard. Methods: Two cohorts were constructed: 30 women who reported ‘normal’ menses and 170 who reported ‘heavy’ menses. Evaluation of menstruation was performed using the PBAC score and by alkaline hematin. Results: Women who reported normal menses were younger (p = 0.071), had lower parity [median parity of 3 (range 1–6) vs. 4 (range 1–12), p < 0.001] and higher hemoglobin levels (11.1 ± 1.1 vs. 10.1 ± 1.6 g/dl, p < 0.001). PBAC scores and MBL by alkaline hematin were significantly correlated (Spearman r = 0.600, p < 0.001). The PBAC score of 150 had a ĸ of 0.593 (95% CI 0.480–0.687) and an area under the curve of 0.796 (95% CI 0.770–0.821). In a multivariable regression PBAC score >150, presence of blood clots and period duration >7 days were independent predicators of heavy menstrual bleeding with an overall area under the curve of 0.858 (95% CI 0.835–0.879). Conclusions: The PBAC score is a simple and accurate tool for semiobjective of MBL that can be used in clinical practice to aid the decision about treatment and follow-up.

The practice of female genital mutilation in Upper Egypt

Objective: To study the prevalence of and reasons for female genital mutilation in an Egyptian village population. Methods: A survey of all 819 households in an Upper Egyptian village near Assiut was conducted in 1992. The mothers of 1732 girls under 20 years of age were interviewed to obtain information about their daughters. When possible, fathers and grandparents were also interviewed. Results: Respectively, 62%, 36.6% and 1.1% were girls who had undergone female genital mutilation (FGM), were to undergo the procedure and were not to have the operation. A total of 67% of the fathers of girls who had undergone FGM and 92% of their mothers were illiterate. FGM was performed most often when girls were 5–9 years old. Almost all procedures (97.5%) were performed by dayas; 1.3% were performed by barbers. A razor was used in 80.7% of the cases, and a knife in 18.5%; in less than 1% (0.7%) of the procedures were medical instruments used. The most prevalent reason for FGM was that it followed customs and traditions (77%). Serious bleeding (5.7%) and pain (3%) were the most commonly reported complications of the procedure. Conclusions: The study raises a number of questions about the experience of FGM by young girls, the reasons for maintaining this practice and the kinds of interventions which might be effective in eliminating it.

The recovery of ovarian function during breast-feeding

The pattern of breast-feeding was daily recorded and the serum concentrations of prolactin (PRL), FSH, LH, estradiol (E2) and progesterone (prog) were measured at weekly intervals in 26 breast-feeding mothers from the time of delivery and up to the resumption of regular ovulation or to the end of the first postpartum year. Twelve postpartum non-breast-feeding women were similarly studied as controls. An algorithm was used to characterize ovulatory events into three types: the first, with evidence highly suggestive of normal ovulation (EHSO), the second, with evidence of probable ovulation (EPO) and the third with evidence indicating questionable ovulation or deficient corpus luteum function (QO/DCT). Pregnancy preceded the first menstruation in one woman in each of the breast-feeding and control groups. Of the 19 breast-feeding women who started to menstruate during the first postpartum year, five had EHSO, one had EPO, 5 had EQO/DCL and 7 had anovulatory (AO) menstruation. The corresponding figures in the 11 controls were 6, 2, 3 and 0. Pregnancy occurred before a second menstruation in one woman in both the study group and the controls. In 18 breast-feeding women observed, the second menstruation was preceded by EHSO in 7, by EPO in 3, by EQO/DCL in one and AO in 7. In 10 controls the corresponding figures were 7, 3, 0 and 0. Out of a total of 79 menstruations observed during breast-feeding the incidence of AO was 30% and of QO/DCL was 15%. In actively breast-feeding mothers, hyperprolactinemia persisted for more than 1 yr. However, menstruation and ovulation occasionally occurred before the drop of PRL to concentrations seen during the normal menstrual cycle. In the majority of women, low E2 levels were present during lactational amenorrhea, but with occasional spikes in some. A few women maintained somewhat high values of E2 for several weeks before the resumption of menstruation. The implications of these hormonal findings to the attempts to improve on the contraceptive effect of breast-feeding are discussed.

The recovery of fertility during breast-feeding in Assiut, Egypt

A longitudinal study of twenty-six breast-feeding and twelve non-breast-feeding postpartum women was conducted in Assiut, Egypt in order to determine the time that ovulation resumed after childbirth, and the effect of breast-feeding frequency on the period of lactational anovulation. Breast-feeding women experienced the onset of follicular development, vaginal bleeding, ovulation and pregnancy significantly later than women who did not breast-feed. Ovulatory and non-ovulatory breast-feeders reported similar frequencies of breast-feeding episodes. The introduction of dietary supplements commonly preceded ovulation. An algorithm using three simple variables observable to the breast-feeding mother was found to predict up to 100% of the first ovulations. All breast-feeding women who did not give supplements and did not have a vaginal bleeding episode by 6 months postpartum were anovular by strict criteria for ovulation. Ovulation did not precede bleeding or supplementation in the women who experienced these events before 6 months, yielding a highly effective formula for preventing unplanned pregnancy by the informed use of breast-feeding.

Prophylactic transcervical amnioinfusion in laboring women with oligohydramnios

Objectives: Evaluation of prophylactic intrapartum amnioinfusion in women with oligohydramnios. Methods: Assiut University Hospital during the period from February 2000 to September 2001, 160 laboring women with oligohydramnios [amniotic fluid index (AFI) ≤5 cm] were randomized into: amnioinfusion and control groups. Inclusion criteria were: term singleton gestation, vertex presentation, cervical dilatation <4 cm, and assuring fetal heart rate (FHR). Trans‐cervical amnioinfusion was done with warmed normal saline. Results: there was a significant increase in AFI after amnioinfusion (P<0.001). The amnioinfusion group showed lower cesarean section rate for fetal distress (P=0.003), lower incidence of abnormal FHR (P=0.006), fewer neonates with Apgar score <7 at 1 min (P<0.001), and 5 min (P=0.009), meconium below vocal cords (P<0.001), umbilical arterial pH<7.1 (P=0.003), and significantly shorter hospital stay (P=0.02). Conclusion: Prophylactic trans‐cervical amnioinfusion is a simple, safe and effective procedure.