Manjeet Shehmar

Uterine fibroids: current perspectives.

Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman’s menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.

Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis

OBJECTIVE To conduct a systematic review and metaanalysis of studies evaluating the regression rate of endometrial hyperplasia with oral progestogens and levonorgestrel-releasing intrauterine system. STUDY DESIGN Searches were conducted on Medline, Embase, Cochrane Library, and Web of Science, and reference lists of relevant articles were examined. The methodologic index for nonrandomized studies was used for quality assessment. Metaanalysis was performed with random effects model. RESULTS There were 24 observational studies (1001 women), of low methodologic quality, evaluating the outcome of regression of endometrial hyperplasia with oral progestogens or levonorgestrel-releasing intrauterine system. Metaanalysis showed that oral progestogens achieved a lower pooled regression rate compared with levonorgestrel-releasing intrauterine system for complex (pooled rate, 66% vs 92%; P < .01) and atypical hyperplasia (pooled rate, 69% vs 90%; P = .03). There was no statistical difference in simple hyperplasia (pooled rate, 89% vs 96%; P = .41). CONCLUSION Oral progestogens appear to induce a lower disease regression rate than Levonorgestrel-releasing intrauterine system in the treatment of endometrial hyperplasia.

Relapse of endometrial hyperplasia after conservative treatment: a cohort study with long-term follow-up

STUDY QUESTION What is the risk of relapse for women with endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system (LNG-IUS) or oral progestogens? SUMMARY ANSWER Relapse of complex endometrial hyperplasia after initial regression occurs often and it occurs less often in women treated with LNG-IUS than with oral progestogens. WHAT IS KNOWN ALREADY The LNG-IUS and oral progestogens are used to treat women with endometrial hyperplasia and achieve regression. There is uncertainty over whether further surveillance for these women is necessary as the risk for relapse is unknown. STUDY DESIGN, SIZE, DURATION A cohort study of 219 women with complex non-atypical or atypical endometrial hyperplasia who were treated and achieved initial regression with LNG-IUS (n = 153) or oral progestogens (n = 66) from August 1998 until December 2007 and followed up for >5 years. The mean length of follow-up was 74.7 ± SD 31.8 months for the LNG-IUS versus 87.6 ± SD 42.2 months for the oral progestogen group. PARTICIPANTS/MATERIALS, SETTING, METHODS We evaluated the proportion of women who relapsed or had hysterectomy after initial regression with LNG-IUS compared with oral progestogens by logistic regression and adjusting for confounding. The time from regression to relapse was explored through a survival analysis. MAIN RESULTS AND THE ROLE OF CHANCE Relapse of hyperplasia occurred in 13.7% (21/153) of women treated with LNG-IUS compared with 30.3% (20/66) of women treated with oral progestogens [adjusted odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.17-0.7, P = 0.005]. Relapse rates over long-term follow-up were lower for complex non-atypical hyperplasia compared with atypical hyperplasia for both LNG-IUS (12.7%, 18/142 versus 27.3%, 3/11, respectively; P ≤ 0.001) and oral progestogens (28.3%, 17/60 versus 50%, 3/6, respectively; P ≤ 0.001). The survival analysis indicates that relapse occurred less often with LNG-IUS at 12, 24, 36, 48, 60 and >60 months of follow-up (hazard ratio 0.37, 95% CI: 0.2-0.7, P = 0.0013). There were no events of relapse after 48 months from regression with oral progestogens, but 5 women treated with LNG-IUS relapsed after 60 months when treatment was discontinued. Hysterectomy rates were lower in the LNG-IUS than oral progestogen group during follow-up (19.6%, 30/153 versus 31.8%, 21/66, respectively, OR = 0.52, 95% CI: 0.27-1, P = 0.05). Endometrial cancer was diagnosed in 2 (11.8%) women who had hysterectomy (n = 17) because of relapse. LIMITATIONS, REASONS FOR CAUTION We are unable to accurately estimate the cancer risk in women who relapse during follow-up as only 17 out of 41 who relapsed underwent hysterectomy. WIDER IMPLICATIONS OF THE FINDINGS Relapse of endometrial hyperplasia after initial regression occurs often and long-term follow-up is advised. STUDY FUNDING/COMPETING INTEREST(S) Ioannis D. Gallos and this study were funded through a grant from Wellbeing of Women (ELS022). No competing interests.

LNG-IUS versus oral progestogen treatment for endometrial hyperplasia: a long-term comparative cohort study

STUDY QUESTION What are the regression and hysterectomy rates for women treated with the levonorgestrel-releasing intrauterine system (LNG-IUS) compared with oral progestogens for endometrial hyperplasia (EH)? SUMMARY ANSWER The LNG-IUS achieves higher regression and lower hysterectomy rates than oral progestogens in the treatment of complex and atypical hyperplasia. WHAT IS KNOWN ALREADY The LNG-IUS and oral progestogens are both equally used to treat women with EH. There is uncertainty about whether the LNG-IUS is a better therapy for EH. STUDY DESIGN, SIZE, DURATION This comparative cohort study included 344 women recruited from August 1998 until December 2010. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with complex non-atypical or atypical EH were treated with the LNG-IUS (n = 250) or oral progestogens (n = 94) in a tertiary referral hospital. We evaluated the proportion of women who regressed or underwent hysterectomy after treatment with the LNG-IUS compared with oral progestogens by logistic regression adjusting for confounding. The time from diagnosis to regression was explored through a survival analysis. MAIN RESULTS AND THE ROLE OF CHANCE The follow-up rate was 95.3%. The mean length of follow-up in the two groups was 66.9 ± SD 35.1 months for the LNG-IUS and 87.2 ± SD 45.5 months for the oral progestogen group. Regression of hyperplasia was achieved in 94.8% (237/250) of patients with the LNG-IUS compared with 84.0% (79/94) of patients treated with oral progestogens (adjusted odds ratio (OR) = 3.04, 95% CI 1.36-6.79, P = 0.001). Hysterectomy rates were lower in the LNG-IUS group during follow-up (22.1, 55/250 versus 37.2%, 35/94, adjusted OR = 0.48, 95% CI 0.28-0.81, P < 0.004). Endometrial cancer was diagnosed in 8 (33%) women who had hysterectomy because of a failure to regress to normal histology during follow-up (n = 24). LIMITATIONS, REASONS FOR CAUTION The observational design cannot exclude residual confounding from unmeasured variables. WIDER IMPLICATIONS OF THE FINDINGS In treating EH, LNG-IUS achieves higher regression rates and lower hysterectomy rates than oral progestogens and should be the first-line therapy. Failure to achieve regression carries a high risk of underlying endometrial cancer and hysterectomy is advised.

Comparing the performance of graduate-entry and school-leaver medical students

Medical Education 2010: 44: 699–705

Current management of endometrial hyperplasia—a survey of United Kingdom consultant gynaecologists

OBJECTIVE To determine current practice for the management of endometrial hyperplasia. STUDY DESIGN We carried out a web-based survey of all UK consultant gynaecologists, from the Royal College of Obstetricians and Gynaecologists (RCOG) database, to evaluate the current practice and to enquire whether a trial between oral progestogens and LNG-IUS for endometrial hyperplasia is required. RESULTS We sent 1090 email invitations and 411 (37.7%) responded to this survey. In total, 338 consultant gynaecologists, who manage patients with endometrial hyperplasia, responded to all items of the survey. The oral progestogens (33.2%) and the LNG-IUS (52.1%) were the most popular choices for managing complex endometrial hyperplasia. The majority of the gynaecologists would explore two conservative choices before embarking into performing a hysterectomy for this condition (130, 52.6%). However, for atypical hyperplasia, the majority of the gynaecologists would perform a hysterectomy (273, 83.2%) and would only consider LNG-IUS or oral progestogens as a second or third option. Two hundred forty-four (72.2%) responded that an RCT for oral progestogens versus LNG-IUS for the management of endometrial hyperplasia is required. There were 171 (50.6%) gynaecologists that would be willing to randomise in such an RCT. CONCLUSION Our survey shows that complex endometrial hyperplasia is managed conservatively in UK, with oral progestogens or LNG-IUS, and atypical endometrial hyperplasia is managed with hysterectomy. An RCT, between oral progestogens and LNG-IUS for endometrial hyperplasia, is required to identify the optimum therapy.

A validity study of the national UK colposcopy objective structured clinical examination--is it a test fit for purpose?

This study examines the validity and reliability of the British Society for Colposcopy and Cytopathology (BSCCP) objective structured clinical examination (OSCE). The BSCCP OSCE results obtained over eight OSCE circuits were analysed using SPSS 15. Face validity and content validity were established from expert opinion and blueprinting. Statistically significant difference was not shown in construct validity through level of experience (P = 0.867, P = 0.822, P = 0.59, P = 0.74, P = 0.12, P = 0.01; these are the P values for each of the patient interaction stations) however, concurrent validity was established against the gynaecology mini‐CEX (sensitivity = 1, specificity = 0.8, positive predictive value = 0.947, negative predicitive value = 1). The reliability of the OSCE’s range from Cronbach’s alpha of 0.617 to 0.775. The OSCE has face, content and concurrent validity.

UKEPSS: The UK Early Pregnancy Surveillance Service for uncommon disorders of early pregnancy and acute gynaecology

A new United Kingdom Early Pregnancy Surveillance Service (UKEPSS) was launched on the 7 February 2014 to investigate uncommon disorders of early pregnancy and emergency gynaecology. UKEPSS (www.birmingham.ac.uk/ ukepss) is a joint initiative of the Association of Early Pregnancy Units (UK), the Early Pregnancy Clinical Studies Group, the Miscarriage Association, the Ectopic Pregnancy Trust, and the University of Birmingham, and is endorsed by the Royal College of Obstetricians and Gynaecologists.

Analysis of an innovative one-stop, hospital-based, outpatient acute gynaecology clinic: model for taking the service to community

Community Sexual and Reproductive Healthcare (CSRH) consultants working closely with general practitioners (GPs) and hospital consultants can offer patients a responsive, efficient, one-stop gynaecology service in the community. We present a retrospective analysis of outcomes of consultations in 914 patients attending a new model acute gynaecology clinic (AGC) at Birmingham Womens Hospital, Birmingham, UK over a 24-month period between July 2010 and June 2012. The AGC is a ‘one-stop’ ‘see and treat’ service for acute gynaecology conditions for patients with severe menorrhagia, irregular vaginal bleeding, pelvic pain, and postoperative complications with symptom duration between 48 hours and 2 weeks. The philosophy is based on the premise that not all urgent gynaecology problems need immediate assessment. Where such assessments can be made by an appropriately skilled senior clinician, using suitable diagnostic tools, unnecessary hospital admission and delays in treatment can result in improved patient safety and experience. A key government National Health Service (NHS) reform objective is to reduce waiting times for specialist care and improve the quality of care and patient experience.1–3 Additionally, the Royal College of Obstetricians and Gynaecologists (RCOG) Standards for Gynaecology 2008 recommend that relevant gynaecology patients should have prompt access to emergency care including diagnostic resources such as ultrasound scanning, and should be reviewed by a consultant within 24 hours of presentation.4 A local audit indicated that a consultant reviewed only 35% of patients within the first 24 hours of admission, whereas 58% of patients never saw a consultant. Furthermore, over 50% of admissions stayed in for longer than 24 (range 18–72) hours, and the main reason for delayed discharge was waiting for an ultrasound scan (65%). This indicated …

Predicting success in graduate entry medical students undertaking a graduate entry medical program

Background: Success in undergraduate medical courses in the UK can be predicted by school exit examination (A level) grades. There are no documented predictors of success in UK graduate entry medicine (GEM) courses. This study looks at the examination performance of GEM students to identify factors which may predict success; of particular interest was A level score. Methods: Data was collected for students graduating in 2004, 2005 and 2006, including demographic details (age and gender), details of previous academic achievement (A level total score and prior degree) and examination results at several points during the degree course. Results: Study group comprised 285 students. Statistical analyses identified no significant variables when looking at clinical examinations. Analysis of pass/fail data for written examinations showed no relationship with A level score. However, both percentage data for the final written examination and the analysis of the award of honours showed A level scores of AAB or higher were associated with better performance (p < 0.001). Discussion: A prime objective of introducing GEM programs was to diversify admissions to medical school. In trying to achieve this, medical schools have changed selection criteria. The findings in this study justify this by proving that A level score was not associated with success in either clinical examinations or passing written examinations. Despite this, very high achievements at A level do predict high achievement during medical school. Conclusions: This study shows that selecting graduate medical students with the basic requirement of an upper-second class honours degree is justifiable and does not disadvantage students who may not have achieved high scores in school leaver examinations.