Kristina Arendas

Endometriosis: Diagnosis and Management

OBJECTIVE To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis. OUTCOMES OUTCOMES evaluated include the impact of the medical and surgical management of endometriosis on womens experience of morbidity and infertility. METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. CONCLUSIONS Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy. EVIDENCE Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1. BENEFITS, HARMS, AND COSTS Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.

Obesity in Pregnancy: Pre-Conceptional to Postpartum Consequences

OBJECTIVE To review the effects of obesity on reproduction and pregnancy outcome. METHODS A search of the literature was performed using key word searching and citation snowballing to identify English language articles published between January 1, 2000, and December 31, 2006, on the subject of obesity and its effects on pregnancy. Once the articles were identified, a thorough review of all results was conducted. Results and conclusions were compiled and summarized. RESULTS Obesity during pregnancy was linked with maternal complications ranging from effects on fertility to effects on delivery and in the postpartum period, as well as many complications affecting the fetus and newborn. The maternal complications associated with obesity included increased risks of infertility, hypertensive disorders, gestational diabetes mellitus, and delivery by Caesarean section. Fetal complications included increased risks of macrosomia, intrauterine fetal death and stillbirth, and admission to the neonatal intensive care unit. CONCLUSION Obesity causes significant complications for the mother and fetus. Interventions directed towards weight loss and prevention of excessive weight gain must begin in the pre-conception period. Obstetrical care providers must counsel their obese patients regarding the risks and complications conferred by obesity and the importance of weight loss. Maternal and fetal surveillance may need to be heightened during pregnancy; a multidisciplinary approach is useful. Women need to be informed about both maternal and fetal complications and about the measures that are necessary to optimize outcome, but the most important measure is to address the issue of weight prior to pregnancy.

Hysteroscopic Resection in the Management of Early-stage Endometrial Cancer: Report of 2 Cases and Review of the Literature

Although endometrial cancer, the most common gynecologic malignancy, is most often diagnosed in postmenopausal women, it affects young women who wish to preserve fertility. The purpose of this article is to describe 2 cases of stage IA endometrial cancer managed conservatively by a combination of hysteroscopic surgery and medical therapy for fertility-sparing purposes, one of which achieved successful pregnancy using assisted reproductive technology, and review the existing literature on the use of hysteroscopic resection in conservative management of endometrial cancer to preserve fertility. The addition of hysteroscopic resection to conservative management of early-stage endometrial carcinoma may be a way to improve response and recurrence rates in women wishing to preserve fertility and can offer other additional benefits, such as a shorter time period to remission and a faster return to fertility. Key factors to success with this approach include an interdisciplinary approach, thorough patient counseling, and the availability of a team experienced in hysteroscopic resection.

Use of Ulipristal Acetate for the Management of Fibroid-Related Acute Abnormal Uterine Bleeding

BACKGROUND Episodes of acute abnormal uterine bleeding related to uterine fibroids can cause significant morbidity. Traditional management with high-dose hormonal regimens may not be as effective when used in women with fibroids. CASE A 32-year-old woman with a 12 cm uterine fibroid presented with an episode of acute abnormal uterine bleeding requiring blood transfusion. In lieu of using a hormonal maintenance regimen after the bleeding had stabilized, the patient was treated with ulipristal acetate 5 mg daily for three months. Amenorrhea was induced rapidly and the patient had no further episodes of acute excessive uterine bleeding. She subsequently underwent a laparoscopic myomectomy with a satisfactory outcome. CONCLUSION Ulipristal acetate has been shown to induce amenorrhea rapidly in women with uterine fibroids, and it can be a useful treatment in the emergency management of fibroid-related acute abnormal uterine bleeding.

Managing Expectations of Surgical Training: A National Perspective on Gynaecologic Endoscopy Practice

OBJECTIVE To determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residency. METHODS An electronic survey was designed, validated, and pre-tested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canadas electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures. RESULTS We received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessary. CONCLUSION Our survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy. Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree. This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs.

The Practical Side of Opportunistic Salpingectomy

The recent SOGC Clinical Practice Guideline (No. 344), “Opportunistic Salpingectomy and Other Methods of Risk Reduction for Ovarian/Fallopian Tube/Peritoneal Cancer in the General Population,” by Salvador et al. is an important resource tool for the generalist obstetrician and gynaecologist in Canada. The rationale and significance of this intervention are well described, and the uptake is likely to be widespread across the country. To complement this guidance, we would like to suggest a set of “practical” tips to help our colleagues safely incorporate this change in practice.

Impact of surgical excision of deep infiltrating bowel endometriosis on health-related quality of life: review of current literature

Background The aim of this study was to systematically review the impact of surgical excision of deep infiltrating endometriosis involving the bowel, on health-related quality of life, based on the currently available literature. Methods A systematic review was completed of English-language publications in the last 10 years, which had assessed the impact of surgical excision on quality of life in patients with deep infiltrating endometriosis of the bowel using standardized, validated quality-of-life questionnaires. Results Fourteen studies were identified. Standardized questionnaires used to assess the therapeutic impact on quality of life were the SF-36, SF-12, EHP-30, EQ-5D and 15D. Overall, women with bowel endometriosis scored lower on quality-of-life measures than the general population. Regardless of which standardized, validated questionnaire was used, surgical treatment had a positive impact on health-related quality of life. Conclusions Endometriosis, in particular deep infiltrating endometriosis of the bowel, has a profound impact on the quality of life of women diagnosed with the condition. Though surgical excision has a positive short-term impact, studies are needed to assess the long-term impact on quality of life in this lifelong, chronic, recurring condition.

Power Morcellation in Gynecologic Surgery: A Survey of Canadian Practice.

Power Morcellation in Gynecologic Surgery: A Survey of Canadian Practice Bougie O, Murji A, Arendas K, Vilos G, Allaire C, Laberge P, Leyland N, Chen I, Singh SS. Obstetrics and Gynecology, The University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada; Obstetrics and Gynecology, St Joseph’s Health Centre, London, Ontario, Canada; Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada; D epartement d’Obst etrique-Gyn ecologie, Universit e Laval, Quebec City, Quebec, Canada

Douleur intermittente au quadrant inférieur droit et présence d’un kyste simple

Une femme de 43 ans presentait des antecedents de trois ans de douleur intermittente au quadrant inferieur droit, ainsi qu’un kyste simple annexiel droit. Elle s’etait presentee au service des urgences a plusieurs reprises au cours des trois annees precedentes en raison de la douleur, mais aucune intervention ne s’etait averee requise. A l’origine, le kyste presentait un diametre de 4 cm; son diametre etait de 6 cm, trois ans plus tard. On estimait qu’il s’agissait d’un simple kyste para-ovarien.

Intermittent Right Lower Quadrant Pain and a Simple Cyst

A43-year-old woman presented with a three-year history of intermittent right lower quadrant pain and a right simple adnexal cyst. She had presented to the emergency department on several occasions over the preceding three years because of the pain, but no intervention had been required. The cyst initially had been 4 cm in diameter and was 6 cm in diameter three years later. It was thought to be a simple para-ovarian cyst.