Reviews in Gynaecological Practice最新文献

Urinary incontinence is a condition of heterogenous aetiology. Classification of the disorder is essential for appropriate management. Much anatomic research has been performed and describes a more integrated mechanism of stress continence control than previously accepted.

Continuing work into the pathophysiology of bladder overactivity sheds light on anatomic as well as cellular mechanisms and offers potential for improving individual therapeutic options.

The separate but complementary roles of follicle stimulating hormone (FSH) and luteinizing hormone (LH) in stimulating folliculogenesis and ovulation are well established. However, it is not known if there are levels under which low LH concentrations may be equally or suboptimal for oocyte quality and subsequent embryonic development competence. On the other hand, there are some conflicting data related to the high levels of LH promoting follicular atresia and early miscarriage. This has lead to the concept of a ‘therapeutic window’ of LH for successful conception in assisted reproductive technology (ART) and ovulation induction. In hypogonadotrophic hypogonadism (HH), rLH is effective for supporting FSH-induced follicular development, in a dose related manner and rLH promotes estradiol secretion, enhances the effect of FSH on follicular growth, and permits successful luteinization. Some patients with prolonged and profound down-regulation response like hypogonadotrophic hypogonadal patients and may benefit from concomitant exogenous administration of LH. Retrospective meta-analyses comparing LH-containing regimens with LH-free stimulations have provided conflicting results in normal ovulatory patients. Until recently, human menopausal gonadotrophin (HMG) preparations were the only source of exogenous LH, however, recombinant human luteinizing hormone (rLH) is now available for clinical use, providing a new treatment option. rLH is well characterized and production is tightly controlled resulting in a highly consistent product. In addition, it has been shown that rLH is as effective but safer than human chorionic gonadotrophin (hCG) in inducing final follicular maturation and ovulation.

Many women would prefer to avoid hormone replacement therapy (HRT) in response to recent publications and instead seek alternative approaches to treat menopause symptoms and the long-term effects of the menopause. Possible options include other pharmacological treatments; however, many of these women would prefer to avoid these too. As there are big cultural variations in the menopause experience, there has been much interest in diet and life style factors that may contribute to this difference. A growing number of women use complementary and alternative therapies either in response to the media hype or disappointment in orthodox medicine, thinking that they provide a safe, natural option. However, they do have the potential for harm, in addition to failing to offer any benefit. Unlike HRT that treats every menopause symptom, often women will have to pursue a number of different alternatives to improve a number of symptoms, needing commitment and patience. Women on low incomes are disadvantaged as rarely alternative treatments are available on the NHS. It is important as health practitioners to ask patients if they are using alternative treatments, particularly herbal remedies that may interact with other medication or have side effects.

In infertility and in assisted conception, the ultimate objective is to understand which are the markers identifying good changes of conception. Although our knowledge of early pregnancy development has recently improved, little is known about the most critical period of human development – the implantation.

The female reproductive system vascularization seems to play an important role in oocyte developmental competence and uterine receptivity. Blood flow modifications in vascularization have been monitored using colour Doppler imaging in many studies. During the last decade, transvaginal colour Doppler has been used to understand the human development.

Power Doppler is a relatively new technique suitable for the study of follicular and endometrial microvasculature.

This review analyzes evidence that point out a relationship between ovarian and uterine vascularity and fertility.

Power Doppler indices of perifollicular vascularization may have a possible important application in assisted conception programs in selecting oocyte-embryos with superior implantation potential.

The degree of endometrial perfusion shown by power Doppler ultrasonography can indicate the more favourable endometrial milieu for successful in vitro fertilization.

Hirsutism can be a have a major physical and psychological impact on a woman. To understand the management of the hirsute woman, it is important to understand the hair growth cycle, and the time scale involved in any treatment. Whilst the underlying cause of any hyper-androgenism is important to ascertain, the majority of cases encountered in practice will be idiopathic. Treatment should be directed at the cause of the problem, and in this regard newer treatments such as metformin for polycystic ovarian syndrome show great promise. Combined with conventional depilitory techniques, reducing the androgen levels, or at least the levels of active androgens, will result in a gradual reduction in hair regrowth. As with all medical problems, investigation begins with a careful history, examination and then investigation directed at the possible cause. A careful explanation of the treatment aims should be undertaken, and the patient should not have unrealistic expectations.

Transvaginal ultrasound has an established role in the assessment of gynaecological patients in almost all areas of the speciality. The incorporation of ultrasound into the initial assessment of the patient presenting acutely with suspected gynaecological pathology, provides an effective and rapid means of diagnosis. This will ideally take place within a dedicated ‘emergency gynaecology unit’, with the gynaecologist performing the ultrasound as an extension of the main clinical examination.

The majority of these women, will be premenopausal. In the absence of a positive urinary pregnancy test, the main distinction that needs to be made is the presence, or not, of a pelvic mass. Transvaginal ultrasound has an established role in the characterization of adnexal masses and their differentiation from leiomyomas, and we will provide an overview of the ovarian, tubal and uterine pathology which may give rise to acute onset symptoms. The presence of adnexal pathology may be coincidental, as the ovary will naturally exhibit a wide variety of cyclical changes, and pain mapping, using the transvaginal probe, will help confirm this.

When considering adnexal torsion, a high degree of clinical suspicion should be maintained as there are no pathognomonic features on ultrasound alone. Even the detection of blood flow within a mass suspected of torsion, using colour Doppler, will not exclude the diagnosis.

By adopting a problem orientated approach to acute pelvic pain, ultrasound can facilitate a rapid diagnosis of most gynaecological problems, and allow appropriate and timely surgical intervention, conservative management or referral to other specialities as indicated.

It is well documented that there is no successful medical treatment for ovarian endometriomas. Transvaginal aspiration is associated with a very high recurrence rate. The use of sclerosing agents as tetracycline and ethanol may reduce the recurrence rate, however, aspiration may possibly result in infection or adhesions.

Surgical treatment of endometriomas is the appropriate approach in the management of associated pain. Laparoscopic surgery proved to be superior to laparotomy in the treatment of endometriomas as it showed less postoperative pain, less blood loss and shorter hospital stay. It is believed that coagulation and ablation of the superficial endometrium lining of the cyst wall is an effective line of treatment as it causes the minimal possible damage to the ovarian tissue. Ovarian cystectomy is considered to be more effective treatment and is associated with lower incidence of recurrence rate. However, there is no available randomized studies to compare both modalities concerning infertility treatment. Assisted reproduction in the form of ovarian stimulation and intrauterine insemination could be tried if the tubes are patent, and IVF is considered as the first line of treatment in extensive adhesions or after failure of surgical treatment.