Jane Wadsworth

POLYCYSTIC OVARIES—A COMMON FINDING IN NORMAL WOMEN

The prevalence of polycystic ovaries (PCO) in normal women of reproductive age was determined by pelvic ultrasound scanning of 257 volunteers who considered themselves to be normal and who had not sought treatment for menstrual disturbances, infertility, or hirsutism. All women had completed a menstrual history questionnaire. 99 women were on oral contraceptives at the time of the study. Of the 158 subjects who were not on oral contraceptives 18% had irregular cycles. 116 (73%) women had normal ovaries and 36 (23%) had PCO. 5 women had multifollicular ovaries and 1 had small, unstimulated ovaries. Only 1 woman with normal ovaries had an irregular menstrual cycle. Of the women with PCO, 76% had irregular cycles, and 6 of the 8 with regular cycles were hirsute. Women with and those without PCO differed in distribution of serum LH concentrations although the median values were similar. 25% of women with PCO had LH concentrations which exceeded the upper limit of the normal range. Thus PCO are common in normal women. Some of these women may have clinical and biochemical markers of PCO, which suggest that PCO in women who consider themselves to be normal is part of the same clinical spectrum as the classic Stein-Leventhal syndrome.

Tissue distribution of protease resistant prion protein in variant Creutzfeldt-Jakob disease using a highly sensitive immunoblotting assay

BACKGROUND Variant Creutzfeldt-Jakob disease (vCJD) has a pathogenesis distinct from other forms of human prion disease: disease-related prion protein (PrP(Sc)) is readily detectable in lymphoreticular tissues. Quantitation of risk of secondary transmission, and targeting of risk reduction strategies, is limited by lack of knowledge about relative prion titres in these and other peripheral tissues, the unknown prevalence of preclinical vCJD, and a transmission barrier which limits the sensitivity of bioassay. We aimed to improve immunoblotting methods for high sensitivity detection of PrP(Sc) to investigate the distribution of PrP(Sc) in a range of vCJD tissues. METHODS We obtained tissues at necropsy from four patients with neuropathologically confirmed vCJD and from individuals without neurological disease. Tissues were analysed by sodium phosphotungstic acid precipitation of PrP(Sc) and western blotting using high sensitivity enhanced chemiluminescence. FINDINGS We could reliably detect PrP(Sc) in the equivalent of 50 nL 10% vCJD brain homogenate, with a maximum limit of detection equivalent to 5 nl. PrP(Sc) could be detected in tissue homogenates when present at concentrations 10(4)-10(5) fold lower than those reported in brain. Tonsil, spleen, and lymph node were uniformly positive for PrP(Sc) at concentrations in the range of 0.1-15% of those found in brain: the highest concentrations were consistently seen in tonsil. PrP(Sc) was readily detected in the retina and proximal optic nerve of vCJD eye at levels of 2.5 and 25%, respectively of those found in brain. Other peripheral tissues studied were negative for PrP(Sc) with the exception of low concentrations in rectum, adrenal gland, and thymus from a single patient with vCJD. vCJD appendix and blood (Buffy coat fraction) were negative for PrP(Sc) at this level of assay sensitivity. INTERPRETATION We have developed a highly sensitive immunoblot method for detection of PrP(Sc) in vCJD tissues that can be used to provide an upper limit on PrP(Sc) concentrations in peripheral tissues, including blood, to inform risk assessment models. Rectal and other gastrointestinal tissues should be further investigated to assess risk of iatrogenic transmission via biopsy instruments. Ophthalmic surgical instruments used in procedures involving optic nerve and the posterior segment of the eye, in particular the retina, might represent a potential risk for iatrogenic transmission of vCJD. Tonsil is the tissue of choice for diagnostic biopsy and for population screening of surgical tissues to assess prevalence of preclinical vCJD infection within the UK and other populations.

Clinical features of women with chronic lower abdominal pain and pelvic congestion

Summary. The clinical features of 35 women with pelvic pain and demonstrable congestion on pelvic venography have been characterized by comparing their symptoms and signs with those of 22 women with pelvic pain due to classical pathology. Women with pelvic pain and congestion had a mean age of 32·4 years, were more often multiparous and had had symptoms for 6 months to 20 years. The pain was dull and aching with sharp exacerbations. In individual women it commonly occurred on one side of the abdomen but unlike the pain due to‘classical pathology’, it could occur on the other side. The pain was exacerbated by postural changes, and walking. Congestive dysmenorrhoea, deep dyspareunia and postcoital ache were common findings in women with pelvic congestion and 60% had evidence of significant emotional disturbance. The combination of tenderness on abdominal palpation over the ovarian point and a history of postcoital ache was 94% sensitive and 77% specific for discriminating pelvic congestion from other causes of pelvic pain.

A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion

The value of medroxyprogesterone acetate (MPA) and of psychotherapy in the treatment of lower abdominal pain due to pelvic congestion was assessed in a randomized controlled trial. Eighty‐four women with abnormal pelvic venography were assigned to one of four treatment groups: MPA alone, MPA plus psychotherapy, placebo alone, and placebo plus psychotherapy. Women were treated for 4 months and thereafter followed up regularly for 9 months with pain assessments, pelvic ultrasound scanning, and hormone measurements. During treatment, MPA showed a significant benefit in terms of a reduction in visual analogue scale pain score, with 73% of women reporting at least 50% improvement compared with 33% of those treated with placebo. At 9 months after the end of therapy there was no overall significant effect of MPA or psychotherapy, but there was an interaction between MPA and psychotherapy, with 71 % of the women in this group showing a ≥50% reduction in pain score. Therapy with MPA is a useful first‐line therapy for women with pain associated with demonstrable pelvic congestion.

Neonatal and maternal morbidity in relation to the length of the second stage of labour

Objective To investigate the relation between the duration of the second stage of labour and subsequent early neonatal and maternal morbidity.

Accuracy of ultrasound measurements of female pelvic organs

Summary. Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo‐oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.

The characteristics of the second stage of labour in 25 069 singleton deliveries in the North West Thames Health Region, 1988

Objective To define the contemporary characteristics of the second stage of labour in one Health Region.

INTRAVENOUS DIHYDROERGOTAMINE TO RELIEVE PELVIC CONGESTION WITH PAIN IN YOUNG WOMEN

The selective venoconstrictor dihydroergotamine (DHE) was given intravenously to 12 women with evidence of pelvic congestion. In 6 the effect of the drug on pelvic veins was observed by pelvic venography. After DHE there was a mean reduction of 35% in the diameter of the pelvic veins measured and the contrast medium cleared rapidly, with a visible reduction in pelvic congestion. In the other 6 women DHE was given during an acute attack of pelvic pain. The effect of the drug on pain relief was assessed by a single-blind crossover trial with intravenous saline as the placebo and by a visual analogue scale to assess the intensity of pain. Pain was significantly lower post-DHE 4 and 8 h and 2 and 4 days after treatment than after placebo. The results confirm a close association between demonstrable pelvic congestion and pelvic pain.

A pilot study of sexual lifestyle in a random sample of the population of Great Britain.

Rates of sexual-partner change and patterns of high-risk behaviour are important determinants of the spread of HIV. We carried out a survey to assess the feasibility of studying sexual lifestyle in a random sample of the British population, aged 16-64 years, in November 1987. Two thousand and seventy-seven households were selected using a multi-stage probability sampling procedure. Seven hundred and eight-five adults participated in a structured interview. The schedule included demographic details, attitudes to AIDS, numbers of sexual partners in different time periods, history of homosexuality and contact with prostitutes. An interview was obtained in 61% of households where contact was made, but the overall response rate was low (48%). There was marked variability between individuals in numbers of sexual partners in given time intervals. Men and women in younger cohorts had experienced first sexual intercourse earlier and had higher numbers of sexual partners than people in older cohorts. Surprisingly few reported high-risk behaviour such as homosexuality and use of prostitution. The methodological problems in trying to obtain unbiased and valid data on sexual behaviour are discussed. Further work is necessary to improve the response rate and questionnaire design.

Assessing participation bias in a sexual behaviour survey: implications for measuring HIV risk.

Objectives:To assess the likelihood of participation bias in a large population-based sex survey, and its possible effect on estimates of HIV risk behaviours. Design:Construction of general hypotheses about non-participants through comparisons of willing and unwilling participants. Methods:British adults aged 16–59 years were surveyed in 1990–1991. Interviews consisted of a face-to-face section combined with a self-completion booklet (n = 18 876). Interviewers recorded interviewee embarrassment. Homosexual experience and number of lifetime heterosexual partners (grouped 0, 1, 2 or more) were recorded prior to booklet offer. Logistic regression was performed, with embarrassment and booklet refusal as outcome variables, assessing their association with sexual behaviour after controlling for demographic variables. Assuming that, in sexual behaviour, non-participants are closer to the embarrassed and the booklet refusers (‘unwilling’ participants) than to others, these analyses provide an indication of the nature of participation bias. Results:Higher refusal and embarrassment rates were associated with both reporting no homosexual experience and fewer heterosexual partners. Conclusions:Under our untestable assumption, these results are consistent with non-participants being generally at lower risk of HIV infection. Methods need to be developed both to reduce participation bias in sex surveys, and to incorporate it in analysis.