Huann-Cheng Horng

Adenomyosis and risk of preterm delivery.

Objective  To evaluate the risk of preterm delivery in patients with adenomyosis.

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy.

OBJECTIVE On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome. STUDY DESIGN Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed. RESULTS A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69. CONCLUSION This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.

Review of myomectomy

Uterine fibroids (also called leiomyomas or myomas) are the most common disorder among women of reproductive age, with an incidence of between 20% and 80%; they are often detected incidentally in routine healthy examinations, through bimanual pelvic and/or ultrasound examination, because uterine fibroids are rarely associated with symptoms. Sometimes, uterine fibroids may be complicated by a variety of symptoms, including menstrual disturbance (e.g., menorrhagia, dysmenorrhea, intermenstrual bleeding), pressure symptoms, bloated sensation, increased urinary frequency, bowel disturbance, or pelvic pain; therefore definite treatment is requested. Hysterectomy may be the first choice for women who have completed their child-birth; however, many women may prefer to keep the uterus if the uterine fibroids-related symptoms can be appropriately controlled. Among these conservative therapies, myomectomy may be one of the most popular methods for the woman who would like to preserve her future fertility, as the majority of symptoms can be relieved by myomectomy; this contributes to the value of this review. This review addresses the use of myomectomy in the management of symptomatic uterine fibroids.

Impact of pregnancy on primary dysmenorrhea

Objective: Because it has been observed that dysmenorrhea can improve after childbirth, this investigation was intended to quantify the impact of both gestational length and mode of delivery on primary dysmenorrhea. Methods: This is an 8‐year prospective observational study. Patients with a history of dysmenorrhea who later gave birth were evaluated for improvement on the severity of dysmenorrhea, with use of visual analogue scale (VAS), and Likert‐type scale. Result: Final analysis involved 3694 patients. Women who had spontaneous delivery would have significantly more improvement than women with cesarean delivery per VAS (term delivery, 51 vs. 33, P < 0.001; preterm delivery, 17 vs. 10, P < 0.001). For first delivery, patients in the spontaneous delivery subgroup were the most likely to have improvement in severity of dysmenorrhea. For second delivery, only patients in the spontaneous delivery subgroup had statistically significant improvement. Conclusion: Both length of gestation and mode of delivery have an impact on primary dysmenorrhea. The most significant improvement occurred after the first delivery.

Natural Progression of Menstrual Pain in Nulliparous Women at Reproductive Age: An Observational Study

Background: Menstrual pain can be alleviated after childbirth. The purpose of this observational study was to evaluate the natural progression of menstrual pain among nulliparous women at their reproductive age. Methods: A questionnaire‐based study of perimenopausal women with a history of primary dysmenorrhea was performed. The study subjects were recruited between July 1, 2001 and June 30, 2005. Severity of menstrual pain was graded using a multidimensional scoring system. Results: A total of 247 nulliparous women with primary dysmenorrhea were enrolled, and of these, 218 patients were eligible for analysis. Patients who had more frequent intercourse (p = 0.016), fewer associated systemic symptoms (p = 0.028), and use of oral contraceptive pills (p = 0.039) tended to have a higher chance of an improvement in dysmen‐orrhea after age 40. Multidimensional scoring distribution over chronologic age revealed that patients had significantly improved menstrual pain after 40 years of age. Conclusion: For nulliparous women with primary dysmenorrhea, the severity of menstrual pain decreased significantly after age 40. More studies are needed to explore this phenomenon from a biochemical or molecular basis.

The impact of gestational diabetes mellitus on postpartum urinary incontinence: a longitudinal cohort study on singleton pregnancies

Please cite this paper as: Chuang C, Lin I, Horng H, Hsiao Y, Shyu I, Chou P. The impact of gestational diabetes mellitus on postpartum urinary incontinence: a longitudinal cohort study on singleton pregnancies. BJOG 2012;119:1334–1343.

Importance of delivered cycles and nomogram for intraperitoneal chemotherapy in ovarian cancer

OBJECTIVE Intraperitoneal (IP) chemotherapy has gained enthusiasm in the treatment of ovarian cancer. Despite having a better survival advantage than intravenous (IV) chemotherapy, IP chemotherapy still poses significant morbidity and complications. Identifying the subset of patients who could best benefit from IP chemotherapy, and those who would least benefit from this treatment, thus avoiding potential complications, is critical. METHODS Between January 2001 and December 2007, 367 patients with stage III epithelial ovarian cancer underwent randomized trial for IP/IV chemotherapy were recruited to construct a nomogram, which is a graphical representation of Cox proportional hazards model adopting six weighted risk factors including age, CA125, IP/IV delivery, stage, histology, and upper abdominal metastases. The nomogram was internally validated for discrimination and calibration. The concordance index was used for quantifying the predictive ability of overall survival with bootstrapping to correct for bias. RESULTS The cycles of completed IP chemotherapy had an impact on overall survival (> or =5 vs. < or =4 cycles, P=0.02). A nomogram for predicting median survival and 5-year survival probability was constructed with a concordance index of 0.72. Upper abdominal tumor metastases (P<0.001) and colon resection (P=0.02) predicted increased chances for early discontinuation of IP chemotherapy. CONCLUSIONS At least five IP cycles are needed to achieve better survival. Nomogram can help to identify the subset of patients who can least benefit from IP chemotherapy, thus avoiding potential IP complications and help to facilitate discussion between patient and physician, risk stratification, and help to guide clinical care.

Clinical presentation and outcome of adult-type granulosa cell tumors: A retrospective study of 30 patients in a single institute

Background: Ovarian adult‐type granulosa cell tumors (GCTs) are characterized as low‐malignant and late‐recurrent ovarian tumors. Although some clinical and pathological prognostic factors have been reported, other factors have yet to be sufficiently investigated for necessary confirmation. The aim of this study was to test the correlation between clinical factors and outcome, based on patients seen in a single institute. Methods: Thirty patients with pathologically confirmed adult‐type GCTs between 1984 and 2010 were reviewed retrospectively. Among them, eight (26.7%) had recurrence, which subsequently contributed to two mortalities. Results: In a comparison of the clinical characteristics of the premenopausal and postmenopausal women with GCT, all of the postmenopausal women had symptoms (100% vs. 63.6%, p = 0.01). With regard to disease recurrence, only abnormal preoperative serum cancer antigen 125 level (≥35 U/mL) was significant (50% vs. 11%, p = 0.03), and residual tumor showed a borderline trend (100% vs. 21.4%, p = 0.06). Other factors, including International Federation of Gynecology and Obstetrics stage, tumor size, tumor rupture prior to or during operation, body mass index, parity, serum estrogen level, and adjuvant therapy, were not statistically significant. Conclusion: Physicians should be alert to the difference in the symptom presentation of GCTs between pre‐ and postmenopausal women, giving particular attention to the usefulness of the preoperative serum level of cancer antigen 125 in patients with GCTs. More evidence is needed to confirm this observation.

Women with endometriosis have higher comorbidities: Analysis of domestic data in Taiwan.

Abstract Endometriosis, defined by the presence of viable extrauterine endometrial glands and stroma, can grow or bleed cyclically, and possesses characteristics including a destructive, invasive, and metastatic nature. Since endometriosis may result in pelvic inflammation, adhesion, chronic pain, and infertility, and can progress to biologically malignant tumors, it is a long‐term major health issue in women of reproductive age. In this review, we analyze the Taiwan domestic research addressing associations between endometriosis and other diseases. Concerning malignant tumors, we identified four studies on the links between endometriosis and ovarian cancer, one on breast cancer, two on endometrial cancer, one on colorectal cancer, and one on other malignancies, as well as one on associations between endometriosis and irritable bowel syndrome, one on links with migraine headache, three on links with pelvic inflammatory diseases, four on links with infertility, four on links with obesity, four on links with chronic liver disease, four on links with rheumatoid arthritis, four on links with chronic renal disease, five on links with diabetes mellitus, and five on links with cardiovascular diseases (hypertension, hyperlipidemia, etc.). The data available to date support that women with endometriosis might be at risk of some chronic illnesses and certain malignancies, although we consider the evidence for some comorbidities to be of low quality, for example, the association between colon cancer and adenomyosis/endometriosis. We still believe that the risk of comorbidity might be higher in women with endometriosis than that we supposed before. More research is needed to determine whether women with endometriosis are really at risk of these comorbidities.

Uterine arterial embolization in the management of severe post-partum hemorrhage: a successful rescue method to avoid peripartum hysterectomy.

Background: Although the effects of uterine arterial embolization (UAE) for the control of post‐partum hemorrhage on menstruation, fertility and future pregnancy have been reported before, domestic reports on long‐term outcomes are lacking. Methods: From April 2001 to March 2005, 9 patients who underwent UAE for post‐partum hemorrhage were evaluated retrospectively. The analyses included both immediate and long‐term outcome, including menstruation, future fertility and subsequent pregnancies. Results: The median follow‐up was 82 months, ranging from 63 months to 108 months. All the women had regular menstruation after UAE treatment, but 5 had hypomenorrhea. Four women attempted pregnancy, and 3 had successful term deliveries. One woman was infertile. Conclusion: UAE appeared to be a safe procedure. Hypomenorrhea was common after UAE treatment (55.6%), although regular menstruation returned successfully. Future pregnancy seemed possible, and without complications.