Reviews in Gynaecological Practice最新文献

Inappropriate use of hormone replacement therapy (HRT) may increase the risk of endometrial cancer. Unopposed oestrogen is associated with the development of endometrial hyperplasia and if continued of endometrial cancer. The addition of progestogen for at least 12 days in each cycle will prevent hyperplasia in the short term but with use over 5 years there will still be an increased risk of endometrial disease. Long cycle therapy with a progestogen course every three months or more will reduce the frequency of bleeding, which will be popular, but protection of the endometrium is less certain.

The addition of continuous progestogen to oestrogen has the merit of correcting endometrial hyperplasia without atypia to normal and in the long-term will keep the endometrium atrophic. There is no increase in the risk of endometrial cancer with such continuous combined regimens and possibly even a reduced risk.

The progestogen in HRT is only required for endometrial protection, so it is logical to give the hormone direct to the endometrial cavity. The Mirena^® intrauterine system that releases levonorgestrel has been available for many years as a contraceptive and treatment for menorrhagia, and recently also for the progestogen component of combined HRT regimens. A smaller experimental device designed for the postmenopausal uterus is being investigated and may become a suitable option in the future.

For women who have had complete removal of a stage 1 endometrial cancer, there is no evidence that subsequent HRT will increase the risk of further disease.

Endometriosis affects millions worldwide. Its symptoms include non-cyclical pelvic pain, dysmenorrhoea, dyspareunia and subfertility. The diagnosis is made by laparoscopy, and operative laparoscopic surgery for endometriosis is also possible. As well as conventional laparoscopic techniques, lasers have been used in laparoscopic surgery for the past two decades. The main advantages of lasers are that they allow surgeons to perform operative surgery via the minimally invasive approach of laparoscopy, the operation is largely bloodless, the injury to the surrounding tissue is highly controllable and postoperative adhesion formation has been shown to be no greater than with conventional methods. The CO₂ laser is the most precise laser for the division of adhesions and the accurate and safe vapourization of deposits of endometriosis. Several types of operative procedure to treat endometriosis have been carried out with the CO₂ laser laparoscope. This article provides an overview of laser physics, the effects on the tissues, the clinical use of lasers, the appearance of endometriotic lesions and the management of endometriosis of the peritoneum, ovary, rectovagina, ureter and bladder by laser laparoscopic techniques.

This review addresses the effects of childbirth on the pelvic floor, urinary continence mechanisms and the perineum. Genitourinary prolapse affects 15% of women and stress incontinence 20–30%. The major risk factors are age and childbirth, with severity increasing with parity. There are three mechanisms of support for the pelvic organs and bladder neck. These are (i) the muscular component: levator ani and urethral sphincter with their intact nerve supply, (ii) the endopelvic fascial connections with the levator ani, and (iii) the posterior angulation of the vagina. Childbirth causes direct myogenic damage, dennervation and defects in the endopelvic fascia along with widening of the urogenital hiatus. Elective caesarean section without labour has in the past thought to be protective. More recent data suggests this effect to be less pronounced and antenatal stress incontinence appears the most important predictive factor for the development of postnatal stress incontinence. The targeting of pelvic floor exercises under direct supervision from a physiotherapist have shown a reduction in the development of short and long term stress urinary incontinence.

Perineal trauma can effect up to 85% of women after vaginal delivery. The consequences of this include perineal pain and dyspareunia lasting up to 12 months postnatally. Nulliparity and the use of forceps have been identified as the major risk factors along with occipito-posterior position, macrosomia and episiotomy as secondary factors. The role of selective mediolateral episiotomy and methods of perineal repair are discussed.

Surgery for intersex is a complex and controversial topic. The traditional practice of surgery for all—usually during infancy—has been challenged by unsatisfied adult patients. There is at present little good outcome data partly due to the problems of non-disclosure of diagnosis, which leaves adult patients absent from follow-up studies. Only recently has more information become available on gynaecological and sexual outcomes. This review covers the three main aspects of intersex surgery: clitoral surgery, vaginoplasty and gonadectomy. Traditional and modern surgical techniques are described as well as any available follow-up data. The current controversies surrounding the role of intersex surgery are summarised.

Microwave endometrial ablation (MEA™) has evolved from a theoretical technology, through rigorous laboratory and clinical testing to become an effective treatment for heavy menstrual loss, with a sound evidence base. The purpose of this article is to review the scientific basis, clinical research, safety and clinical applications of this endometrial ablative technique.

The German embryo protection law (Embryonenschutzgesetz, ESchG) does not allow embryo selection, but only selection at the pronuclear stage. Furthermore, only as many pronuclear stage zygotes are allowed to be selected as are planned to be transferred in the same cycle. This means that after pre-selection of, for example, three pronucleated zygotes, these three must be transferred on the same or the subsequent day. A second selection process is not allowed. Non-selected pronuclear stage zygotes are allowed to be cryopreserved for a subsequent transfer.

The same situation is present in other European countries such as Swizerland and Italy. it is illegal to cryopreserve an oocyte after fusion of the pronuclei (PN). The idea of these laws was to avoid ethical problems related to cryopreservation of surplus embryos or wastage of embryos, because these have, according to these laws, the status of individual persons.

The current situation initiates much interest in developing a refined method of cryopreserving human pronuclear zygotes. The following article will discuss that issue in details.

Menorrhagia is common, affecting 50% of the female population. It is becoming more apparent that haematological causes, many often under-diagnosed, may be responsible. With increasing laboratory sophistication, platelet functional defects, von Willebrand disease (vWD) and clotting factor deficiencies are diagnosed more frequently. Menorrhagia may be the first clinical manifestation of a bleeding disorder therefore timely diagnosis and management are essential especially if surgery is to be considered as a definitive treatment for menorrhagia not responding to medical management.