Robert W. Shaw

Assessment of menstrual blood loss using a pictorial chart

Summary. Objective menstrual blood loss measurements (in ml) were compared with the score obtained from a pictorial blood loss assessment chart (PBAC) which took into account the degree to which each item of sanitary protection was soiled with blood as well as the total number of pads or tampons used. Twenty eight women used the chart during 55 menstrual cycles and a single observer assessed 122 cycle collections in a similar manner. A pictorial chart score of 100 or more, when used as a diagnostic test for menorrhagia, was found to have a specificity and sensitivity of >80%. Demonstration of the relation between self assessed pictorial chart scores and the objective measurement of blood loss enables us to provide a simple, cheap and reasonably accurate method of assessing blood loss before embarking upon treatment.

Gonadotropin-releasing hormone analogues for the treatment of endometriosis: long-term follow-up

OBJECTIVE To determine the long-term recurrence rate of endometriosis after treatment with gonadotropin-releasing hormone analogues (GnRH-a). DESIGN A historical prospective study. SETTING Royal Free Hospital, London, a tertiary referral center for the treatment of endometriosis. PATIENTS One hundred thirty patients with endometriosis had treatment with GnRH-a buserelin acetate, goserelin, and nafarelin acetate between the years 1985 and 1987. Patients no longer being followed in the gynecology clinic were sent a questionnaire to determine their state of health. Information was also requested from the patients general practitioner. MAIN OUTCOME MEASURES The cumulative recurrence rate for the fifth year after treatment ended was 53.4%. RESULTS Patients with a higher disease stage at the outset were more likely to experience recurrence and experience it earlier than patients with minimal disease. Fifth-year recurrence rates were 36.9% for minimal disease and 74.4% for severe disease. The change in endometriosis stage classification scores at second-look laparoscopy for those patients whose disease recurred after treatment was not significantly different from those whose disease did not recur during the study period. CONCLUSIONS Patients with endometriosis treated with GnRH-a are highly likely to suffer a recurrence of their disease, particularly if their disease is severe at the outset.

OVARIAN ELECTROCAUTERY VERSUS HUMAN MENOPAUSAL GONADOTROPHINS AND PURE FOLLICLE STIMULATING HORMONE THERAPY IN THE TREATMENT OF PATIENTS WITH POLYCYSTIC OVARIAN DISEASE

Eighty‐eight clomiphene citrate‐resistant infertile patients with oligomeno‐rrhoea or amenorrhoea attributable to polycystic ovarian disease were divided at random into three groups. Twenty‐nine patients were treated with ovarian electrocautery, 30 with human menopausal gonadotropins (hMG) and 29 with pure follicle stimulating hormone (FSH). Successful ovulation was induced in 71‐4, 70‐6 and 66‐7% of the cycles in the groups respectively. Ten patients conceived after electrocautery and pure FSH therapy while 15 conceived after hMG medication (chi‐squared = 1 ‐6464, P = 0–439). The six‐cycle cumulative pregnancy rate in the three consecutive groups was 521, 55‐4 and 38‐3%. Four further pregnancies were achieved after treating 10 patients in the electrocautery group with clomiphene citrate (100 mg/day for 5 days) for 25 cycles. The rate of pregnancy wastage in the corresponding groups was 21‐4, 53‐3 and 40% (chi‐squared = 3–127, P = 0–2039). Ovarian electrocautery is equally effective as hMG and pure FSH in the treatment of PCO patients resistant to clomiphene citrate therapy.

Doppler assessment of uterine blood flow changes in patients with fibroids receiving the gonadotropin-releasing hormone agonist Buserelin *

Uterine arterial blood FVWs were studied by doppler ultrasound in eight patients with large uterine fibroids who were treated with the GnRH agonist Buserelin intranasally for 4 months. At the end of treatment, reductions in the uterine and discrete fibroid volumes were associated with significant increases in the mean RI values for the uterine (P less than 0.01) and fibroid (P less than 0.001) vasculature, thus indicating reduction in blood flow.

Presenting a routine screening test in antenatal care: Practice observed

Peoples knowledge of screening tests for which they are eligible and which they may have undergone is frequently low. The aim of the current study is to determine the extent to which this is due to how a test is offered and explained. Routine consultations (n = 102) between midwives, obstetricians and pregnant women were tape-recorded to determine how a routine screening test for fetal abnormalities (maternal serum alpha-fetoprotein) is presented. The test was presented in the vast majority of consultations. Overall, little information was provided about the test, the conditions screened for, and the meaning of either a positive or a negative result. Screening was presented in such a way as to encourage women to undergo the test. The way in which routine prenatal screening is presented is unlikely to maximise informed decisions about whether to participate in this screening programme. Factors likely to be influencing test presentation include knowledge, attitudes and skills of staff, as well as the attitudes of pregnant women. The results of this study highlight a need to train the heath professionals implementing screening programmes in how to inform people fully about low probability but serious events without alarming them unduly, or reassuring them falsely.

An open randomized comparative study of the effect of goserelin depot and danazol in the treatment of endometriosis

OBJECTIVE To compare the efficacy and safety of goserelin depot and danazol for endometriosis. DESIGN Open, randomized comparative trial. SETTING Multicenter European academic clinical institutions. PATIENTS A total of 307 patients with laparoscopically diagnosed endometriosis were randomized to goserelin (n = 204) or danazol (n = 103); 249 patients underwent second look laparoscopy (175 received goserelin and 74 danazol) and were analyzed for efficacy. INTERVENTIONS A 3.6-mg depot of goserelin monthly subcutaneously or oral danazol 200 mg three times a day administered for 24 weeks. MAIN OUTCOME MEASURES Efficacy assessments were based on changes in visible deposits at laparoscopy before and after treatment and subjective symptom scores at 4-week intervals during treatment and 8-week intervals after treatment for up to 24 weeks. Safety was assessed by adverse event reporting and clinical laboratory measures. RESULTS There were similar proportions of symptomatic (73%) and asymptomatic (but infertile) (27%) and comparable distribution of different severity of endometriosis randomized to each treatment. Significantly fewer patients randomized to goserelin (6.4%) withdrew during treatment compared with 20.4% randomized to danazol (P less than 0.05). There were significantly reduced visible deposits of endometriosis found post-treatment (P less than 0.0001) within each group but no differences between the treatments. The mean total subjective symptoms scores remained significantly less than entry at 24 weeks post-treatment (P less than 0.05). Hypoestrogenic side effects were more common in those receiving goserelin, particularly hot flushes, but anabolic/androgenic side effects of weight gain and muscle cramps were more common in those receiving danazol. CONCLUSIONS The monthly administered 3.6-mg depot preparation of goserelin was highly effective at inducing resolution of endometriotic implants and relieving the symptoms of endometriosis with prevention of their return during 24 weeks follow-up in the majority of patients. However, results were not significantly different from those achieved with danazol 600 mg/d.

Long-term follow-up of patients with uterine fibroids after treatment with the LHRH agonist buserelin

Summary. Ten patients with uterine fibroids palpable abdominally were treated with the luteinizing hormone‐releasing hormone (LHRH) agonist buserelin, administered intransally, 300 μg three times daily, for 6 months, and were then followed for a further 12 months. Oestrogen levels were markedly reduced in all patients during treatment. At the end of treatment the mean volume reductions were 44·4% (SEM 3·5) for total uterine volume and 57·3% (SEM 7·4) for volume of discrete fibroids as assessed ultrasonically. There was also marked improvement in associated symptoms. After buserelin therapy was stopped, the total uterine and discrete fibroid volumes returned to, or slightly exceeded, pretreatment volumes within 6 months in five patients, and by 12 months in two patients. Three other patients who underwent surgery for their fibroids during the first 4 months after treatment showed regrowth of fibroids to pretreatment size, Four comparable asymptomtic untreated patients showed no significant change in the total uterine or fibroid volume during six monthly ultrasonic assessments. Buserelin therapy may facilitate rather than replace surgery in the management of uterine fibroids.

The effects of gonadotrophin-releasing hormone agonists on iliac crest cancellous bone structure in women with endometriosis.

The administration of gonadotrophin-releasing hormone (GnRH) analogs to premenopausal women causes hypoestrogenism and bone loss, but the effects on cancellous microstructure have not been determined. In this study we have assessed bone structure in transiliac biopsies obtained from women before and after treatment for endometriosis with GnRH analogs. Twenty-one premenopausal women were studied, paired biopsies being obtained in 13; five women received both GnRH analogs and Org OD 14 (Tibolone, Livial). Comparison of pre- and post-treatment biopsies in women treated only with GnRH analogs showed a reduction in indices related to connectivity (node-to-terminus ratio, node-to-loop strut length, p < 0.02) and increase in inversely related indices (terminus-to-terminus and node-to-terminus strut length, p < 0.03). No significant changes were seen in any of the structural indices in women receiving both GnRH and Org OD 14 therapy. Activation frequency and bone formation rate at tissue level increased in women treated with GnRH agonists alone, although this change was not statistically significant. Our results suggest that bone loss induced by GnRH analogs may be associated with adverse effects on cancellous microstructure which are unlikely to be reversed following cessation of therapy. Concurrent treatment with Org OD 14 appears to prevent these changes.

Direct inhibition of ovarian steroidogenesis by Cortisol and the modulatory role of 11β‐hydroxysteroid dehydrogenase

OBJECTIVE The association of adrenal hyperactivity with ovarian dysfunction may involve direct inhibition of ovarian steroidogenesis by glucocorticoids. Therefore, the objectives of this study were to investigate the direct effects of Cortisol on luteinizing hormone (LH) action in human granulosa‐lutein cells and the modulation of this interaction by ovarian 11β‐Miydroxysteroid dehydrogenase (11βHSD).

Perceived risk not actual risk predicts uptake of amniocentesis

Summary. A consecutive cohort of 71 women eligible for amniocentesis because they were over 38 years of age completed questionnaires during the first trimester of pregnancy. Sixty‐one women underwent amniocentesis, an uptake rate of 86%. Uptake was associated with a less negative attitude towards termination of an affected baby and a higher perceived risk of the fetus being abnormal. It was not associated with actual age‐related risks. There was no significant relation between actual risk and perceived risk. The results of this study suggests that it is important for doctors to understand the basis of womens decisions to have amniocentesis, and the difference between actual and perceived risk if they are to communicate effectively with women about the test and their options.