Reviews in Gynaecological Practice最新文献

Menopause is associated with vasomotor symptoms, which can affect the quality of life of some women. Although oestrogen replacement therapy is an effective treatment yet many women declines its use especially with the highly publicised findings of Women Health Initiative trials. Although oestrogen withdrawal is the main cause of hot flushes, neurotransmitter modulators are involved in its pathophysiology. Selective serotonin reuptake inhibitors as venlafaxine, flouxetine and paroxetine have been shown to reduce hot flushes by nearly 60% and are generally well tolerated. Trials on gabapentin, another group of neurotransmitter modulators, yielded similar results. Clonidine is a central α-adrenergic agonist, which is only modestly effective in reducing hot flushes. Their side effects may preclude their use but may be a suitable option for hypertensive patients with hot flushes. Non-prescription medications are widely popular as natural alternatives to hormone replacement therapy despite the lack of enough data regarding their safety. The current available evidence suggests that phytoestrogens are ineffective in treating hot flushes. Trials of black cohosh lack methodological quality and yielded conflicting results. Other herbal medicines are only included in isolated trials. Systemic progestogens can be effective in treating hot flushes but their long-term effect in breast cancer survivors is uncertain. There is little evidence to support progesterone cream for treatment of vasomotor symptoms. Many women might benefit of life style modifications and regular physical exercise.

The standard surgical procedure for uterovaginal prolapse is vaginal hysterectomy and reconstruction of the uterosacral ligaments. Women who wish to have further children are generally advised to delay surgery until their family is complete. Some women may still wish to consider treatment before family completion if symptoms are severe and others may wish to conserve the uterus for personal reasons. In addition hysterectomy has specific risks, may be a causative factor in subsequent bladder symptoms and does not specifically cure the prolapse. A variety of other surgical procedures to conserve the uterus have been described and many show high rates of symptom improvement in the short term. Fertility after conservative surgery for prolapse is unknown as very few pregnancies have been reported in the literature after such surgery.

Abdominal myomectomy is the commonest conservative surgical procedure offered to patients with symptomatic fibroids and as a fertility enhancing procedure to some women with large intramural fibroids when no other cause for subfertility is evident. Historically myomectomy has been considered to be a complex procedure with high risk of complications. However, there is no evidence to support this assumption and recent studies have shown that the morbidity of myomectomy and hysterectomy is comparable. In recent times, new treatment strategies with a minimally invasive approach have evolved but are available only in selected centres and their efficacy has not been evaluated in the light of well-designed research trials. Therefore, myomectomy remains the mainstay of surgical treatment in women who wish to retain their uterus. This review aims to dispel the misconceptions about morbidity of myomectomy and provides an evidence-based account of the measures that can be taken to minimise it.

Pelvic organ prolapse is a common health problem, and though severe morbidity is rare, it can have marked effects on quality of life. The treatment of vaginal vault prolapse can be a difficult and challenging problem and requires a thorough knowledge of the anatomy and physiology of the lower genital tract. A detailed history and clinical evaluation is required in order to plan the appropriate choice of procedure.

The procedure of choice for reconstructive surgery to the vaginal vault should be tailored to the individual patient and be of low morbidity and mortality, but at the same time with long-term durability. There is a need for large randomised trials to evaluate surgical techniques to correct vaginal prolapse and related urinary, bowel, and sexual dysfunction.

Polycystic ovary syndrome (PCOS) is a heterogeneous condition that represents a continuous spectrum from asymptomatic women with polycystic ovaries demonstrated on ultrasound through to those with the classic features of infertility, obesity and hyperandrogenaemia. It is now generally believed to be a metabolic and endocrine condition secondary to relative insulin resistance and compensatory hyperinsulinaemia. Hyperinsulinaemia is thought to cause abnormal ovarian androgen metabolism and altered ovarian gonadotrophin response resulting in anovulation, oligoamenorrhoea and features of hyperandrogenism. Logically, therapeutic strategies aimed at correcting the insulin resistance (weight loss and insulin sensitisers) would in theory make more sense than symptom relief. The potential increased risks of cardiovascular disease and non-insulin-dependent diabetes mellitus would also be obviated. In practice, however, several gaps exist in our current knowledge of the pathophysiology of PCOS with resulting challenges in strategies that aim primarily to correct insulin resistance. This article discusses the current understanding and management of polycystic ovary syndrome. Novel future research directions are suggested.