Sari Kives

Progestagens and anti‐progestagens for pain associated with endometriosis

BACKGROUNDnEndometriosis is a chronic inflammatory condition defined by the presence of glands and stroma outside the uterine cavity. It occurs in 7% to 10% of all women of reproductive age and may present as pain or infertility. The pelvic pain may be in the form of dysmenorrhoea, dyspareunia or pelvic pain. Initially a combination of estrogens and progestagens was used to create a pseudopregnancy and alleviate the symptoms associated with endometriosis. Progestagens alone or anti-progestagens have been considered as alternatives because they are inexpensive and may have a better side effect profile than other choices.nnnOBJECTIVESnTo determine the effectiveness of both the progestagens and anti-progestagens in the treatment of painful symptoms ascribed to the diagnosis of endometriosis.nnnSEARCH METHODSnWe used the search strategy of the Menstrual Disorders and Subfertility Group to identify all publications which described or might have described randomised controlled trials (RCTs) of any progestagen or any anti-progestagen in the treatment of symptomatic endometriosis. We updated the review in 2011.nnnSELECTION CRITERIAnWe considered only RCTs which compared the use of progestagens and anti-progestagens with other interventions, placebo or no treatment for the alleviation of symptomatic endometriosis.nnnDATA COLLECTION AND ANALYSISnWe have added six new studies, bringing the total of included studies to 13 in the update of this review. The six newly included studies evaluated progestagens (comparisons with placebo, danazol, oral or subdermal contraceptive, oral contraceptive pill and danazol, gonadotrophin-releasing hormone (GnRH) analogue and other drugs). The remaining studies compared the anti-progestagen gestrinone with danazol, GnRH analogues or itself.nnnMAIN RESULTSnThe progestagen medroxyprogesterone acetate (100 mg daily) appeared to be more effective at reducing all symptoms up to 12 months of follow-up (MD -0.70, 95% CI -8.61 to -5.39; P < 0.00001) compared with placebo. There was evidence of significantly more cases of acne (six versus one) and oedema (11 versus one) in the medroxyprogesterone acetate group compared with placebo. There was no evidence of a difference in objective efficacy between dydrogesterone and placebo.There was no evidence of a benefit with depot administration of progestagens versus other treatments (low dose oral contraceptive or leuprolide acetate) for reduced symptoms. The depot progestagen group experienced significantly more adverse effects.There was no overall evidence of a benefit of oral progestagens over other medical treatment at six months of follow-up for self-reported efficacy. Amenorrhoea and bleeding were more frequently reported in the progestagen group compared with other treatment groups.There was no evidence of a benefit of anti-progestagens (gestrinone) compared with danazol. GnRH analogue (leuprorelin) was found to significantly improve dysmenorrhoea compared with gestrinone (MD 0.82, 95% CI 0.15 to 1.49; P = 0.02) although it was also associated with increased hot flushes (OR 0.20, 95% CI 0.06 to -0.63; P = 0.006).nnnAUTHORS CONCLUSIONSnThere is only limited evidence to support the use of progestagens and anti-progestagens for pain associated with endometriosis.

Screening for Bacterial Vaginosis at the Time of Intrauterine Contraceptive Device Insertion: Is There a Role?

OBJECTIVEnTo estimate the prevalence of bacterial vaginosis (BV) among women attending outpatient gynaecology clinics for insertion of an intrauterine contraceptive device (IUD); and to describe any differences between BV-positive and BV-negative women at one month after insertion with respect to four primary clinical outcomes: expulsion of IUD, pain, fever > 38 ºC, and heavy bleeding.nnnMETHODSnWe carried out an observational prevalence study between March 2008 and March 2009. Seventy women were each followed for one month. Vaginal cultures for BV were obtained before and at one month after IUD insertion, and women were assessed for complications at one month after insertion. Thirty-eight women had a copper IUD (Cu-IUD) inserted and 32 had a levonorgestrel-releasing IUD (LNG-IUD) inserted. Bacterial vaginosis was diagnosed using Nugents scoring and Gram stain evaluation of the cultures. Frequency distributions, Student t test, and Fisher exact test of independence were used to analyze the data.nnnRESULTSnThe prevalence of BV was 7.1%. Five women were found to be BV positive at the time of IUD insertion, and none experienced any clinical complications. One BV-negative patient developed a tubo-ovarian abscess three months after LNG-IUD insertion, and another BV-negative patient reported persistent, thick vaginal discharge after Cu-IUD insertion. Of 43 BV-negative patients who had repeat cultures performed at their one-month follow-up visit, four (9.3%) shifted from having normal flora to being BV positive. We found no significant relationship between a patients BV status and any clinical outcome.nnnCONCLUSIONnThe incidence of BV in this study was lower than that described in other populations. No clinical complications occurred among the BV-positive women. Screening for BV prior to IUD insertion is neither currently recommended, nor supported by our study findings.

Does Ulipristal Acetate Affect Surgical Experience at Laparoscopic Myomectomy

STUDY OBJECTIVEnTo compare surgical experience of laparoscopic/robotic myomectomy in premenopausal patients pretreated with ulipristal acetate (UPA) with women not hormonally pretreated.nnnDESIGNnA retrospective, multicenter cohort study of laparoscopic/robotic myomectomy procedure videos (Canadian Task Force Classification III).nnnSETTINGnMultiple university-affiliated tertiary care hospitals.nnnPATIENTSnFifty-five premenopausal women who underwent laparoscopic/robotic myomectomy for intramural myomas and were either pretreated with 3xa0months of UPA or had no hormonal pretreatment.nnnINTERVENTIONSnLaparoscopic/robotic myomectomy surgical videos were independently reviewed by 2 gynecologists blinded to whether or not patients received pretreatment with UPA. Each procedure was scored using a novel 22-point surgical global rating tool containing 6 subscales: depth of myometrial incision, ease of myoma-myometrium cleavage plane identification, ease of myoma detachment, blood loss during myoma detachment, myometrial blood loss after myoma detachment, and myoma consistency.nnnMEASUREMENTS AND MAIN RESULTSnParticipating surgeons submitted 55 videos of laparoscopic/robotic myomectomy procedures recorded over a 3-year period (2012-2015). Fifty met the inclusion criteria (25 UPA-treated patients and 25 patients without hormonal pretreatment). Patients treated with UPA were more likely to be older than patients with no medical pretreatment (mean agexa0=xa033.5 vs 38.3xa0years, pxa0=xa0.002). There were no statistically significant differences regarding other baseline characteristics such as the largest diameter of myoma removed, the number of myomas removed, or the estimated blood loss. There was no difference in the physician assessors mean global rating score for patients with UPA pretreatment versus no pretreatment (12.4 vs 13.4, pxa0=xa0.23). Within the 6 subscales, no differences were observed between the 2 groups. Each video was graded independently by 2 assessors, and there was high inter-rater agreement for the total score and each subscale.nnnCONCLUSIONnThere was no difference in surgical experience for myomectomies of patients pretreated with UPA versus those without medical pretreatment.

Cecal Perforation Due to Paralytic Ileus Following Primary Caesarean Section

BACKGROUNDnReports of cecal perforation complicating a Caesarean section postoperatively are very uncommon. Cecal perforations often are due to an antecedent bowel obstruction.nnnCASEnA 39-year-old primigravid woman presented with obstructed labour at a cervical dilatation of 6 cm. An uncomplicated Caesarean section was performed. Postoperatively, the patient developed signs consistent with a bowel obstruction and was managed conservatively. A perforated viscus was confirmed via imaging on the third and fourth postoperative days. The patient underwent laparotomy with resection of a perforated cecum, and she recovered well.nnnCONCLUSIONnAlthough uncommon after a Caesarean section, cecal perforation should be suspected if a patient presents with symptoms of a prolonged bowel obstruction. Early identification and prompt imaging are the mainstays of treatment for these patients.

Pregnancy Outcomes Following Ulipristal Acetate for Uterine Fibroids: A Systematic Review

OBJECTIVEnTo determine pregnancy and fetal outcomes following treatment with ulipristal acetate (UPA) for symptomatic uterine fibroids.nnnMETHODSnWe conducted a systematic review and case series. We searched MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Register from inception to February 2017. From January 2014 to July 2017, we carried out a multi-centre retrospective chart review. All human studies that reported at least one pregnancy following UPA treatment were included. The case series included patients who conceived during/following UPA treatment. Titles and abstracts were screened for eligibility by two independent reviewers, and full texts were evaluated for inclusion and study quality. Data from the systematic review and case series were synthesized and reported separately.nnnRESULTSnSeven studies were included (six case reports, one retrospective series) and contributed 24 post-UPA pregnancies (19 live births, six spontaneous abortions [SA]). The case series contributed 47 post-UPA pregnancies (31 live births, 13 SA, 1 fetal death, 2 terminations, 1 ongoing). In total, 71 pregnancies were evaluated (44 underwent myomectomy post-UPA; 27 without interval surgery). Five pregnancies occurred during UPA use (10-36 days of exposure) and resulted in three live births, one SA, and one termination. Five women who did not undergo interval myomectomy experienced delivery complications related to their fibroid.nnnCONCLUSIONSnThis is the first systematic review and largest reported case series evaluating pregnancy outcomes following UPA treatment for uterine fibroids. UPA alone, or in conjunction with surgery, can permit conception and favorable pregnancy outcomes.

Fertility and Patient Satisfaction After Robotic-Assisted Laparoscopic Myomectomy: A Canadian Vantage [90]

INTRODUCTION: Uterine fibroids in premenopausal women may be associated with abnormal uterine bleeding, pain, infertility, and pregnancy loss. The objective of this study is to evaluate fertility outcomes, symptom relief, and cosmetic satisfaction in patients who underwent robotic-assisted laparoscopic myomectomy in Canada. METHODS: A prospective qualitative assessment of women who underwent robotic-assisted laparoscopic myomectomy at St. Michaels Hospital between October 2008 and September 2013 was completed with Research Ethics Board approval. Through telephone interviews, participants were asked about pregnancy outcomes, postsurgical symptoms, and cosmetic satisfaction. These results as well as uterine fibroid characteristics were analyzed. RESULTS: Of 77 women who underwent robotic-assisted laparoscopic myomectomy from October 2008 to September 2013, 63 agreed to participate (mean age 38 years). After robotic-assisted laparoscopic myomectomy, 34 women (54%) attempted to conceive (for 1 month or more). Of those attempting to conceive, 21 (21/34 [62%]) became pregnant and eight (8/34 [24%]) were unable to conceive after 6 or more months. Sixteen women (16/34 [47%]) had successfully delivered or were more than 24 weeks pregnant at the time of writing. Seven (7/34 [21%]) women experienced at least one miscarriage. All women who delivered after robotic-assisted laparoscopic myomectomy had a cesarean delivery. Forty-four women (44/63 [70%]) were “satisfied” or “extremely satisfied” with the cosmetic appearance of their scar. Those unsatisfied all had hypertrophic scarring. Fifty-six women (56/63 [89%]) were asymptomatic after their robotic-assisted laparoscopic myomectomy. Uterine fibroids recurred in 24 women (24/63 [38%]) at the time of data collection, all diagnosed by radiologic imaging. The majority of these were asymptomatic. CONCLUSION: Robotic-assisted laparoscopic myomectomy offers a minimally invasive option for myomectomy, following which fertility and reproductive success are comparable with figures in the general population.