Reviews in Gynaecological Practice最新文献

Polycystic ovary syndrome (PCOS) in the adolescent is a frequent cause of menstrual irregularity (mostly persistent oligomenorrhea), acne, hirsutism and even premature pubarche. Typical ultrasound findings in the ovary can complete the clinical diagnosis. The obese especially should also be examined for impairment of insulin sensitivity and glucose tolerance as these, if untreated, may compromise long-term health. The androgen excess of PCOS acts on the pilo-sebaceous unit to cause acne and hirsutism which often have a disturbing psychosocial effect on the teenager. Early detection of the syndrome and its treatment with anti-androgens can save much anguish and for the overweight, loss of weight is an integral part of correct management. The long-term use of metformin for adolescents is still hotly debated but preliminary data suggest it may have a role for symptomatic, and maybe also preventative treatment.

The increased survival advantage for patients diagnosed with early stage ovarian cancer suggests that screening programs that detect early stage disease might have an impact on disease mortality. Attempts are being made to develop effective screening methods for early ovarian cancer in women without symptoms, using a variety of serum tumour markers, proteomic patterns and ovarian vascular and morphological features. Three main screening strategies have emerged, one utilising transvaginal scanning as the primary test (ultrasound strategy), one involving measurement of the serum tumour marker CA125 as the primary test with transvaginal scanning as the secondary test (multimodal strategy) and another utilising both transvaginal scanning and measurement of CA125 together as both a primary and secondary test (combined strategy). Large randomised trials are now underway to provide definitive data on the impact of screening on mortality and address morbidity, health economics and psychosocial issues.

This article reviews the most recent studies of tension free vaginal tape (TVT) procedure. It describes studies investigating the procedure’s mechanism in correcting stress incontinence and its efficacy and morbidity. Tension free vaginal tape has shown promise and is increasingly becoming popular for the treatment of urodynamic stress incontinence (USI) because of minimal access, rapid recovery time and good results.

This review explains the mode of action, advantages, limitations and versatility of the ultrasonically activated scalpel in modern gynaecologic operative laparoscopy. When compared to other energy sources, the technique is safe, efficacious, cost-effective and easy to use. It is highly recommended for use in modern day-to-day clinical practice of trainers and trainees in gynaecology.

Malignancies of the genital tract in pregnancy are uncommon. When they are encountered in pregnancy there is always a conflict between optimal maternal therapy and fetal well-being. In most instances the cancer should be managed as though the patient were not pregnant. Surgery is preferred for the various site-specific cancers; the timing and mode of delivery should be individualised. The commonest gynaecological cancer encountered is cervical cancer. Delivery by classical Caesarean section followed by radical hysterectomy appears to be the method of choice for cervical cancer; significantly poorer survivals were observed if this was delayed until the puerperium.

Ovarian cancer, the second most common gynaecological cancer in pregnancy has a good prognosis due to early presentation in the majority. Malignant germ-cell tumours are just as common as epithelial ovarian cancers.

The association of pregnancy with other gynaecological malignancies—carcinoma of endometrium, vagina, fallopian tube, vulva, and choriocarcinoma are discussed.

Cytotoxic drugs are highly teratogenic in the first trimester; other fetal problems can arise when these are used after 12 weeks’ gestation. Therefore, cytotoxic chemotherapy is best avoided in pregnancy.

Primary peritoneal serous carcinoma (PPSC), also commonly called primary peritoneal cancer, often presents with clinical features identical to advanced epithelial ovarian carcinoma (EOC). The diagnosis is made only after a laparotomy. The main differentiating feature is advanced peritoneal involvement with tumour without gross involvement of the ovaries. In the absence of any randomised trials, the management of PPSC is very similar to that of EOC, with primary debulking surgery and adjuvant chemotherapy. The prognosis appears to be related to the volume of residual disease, with minimal disease providing a longer disease free interval.

Polycystic ovaries (PCO) is the commonest endocrine disorder in women. It is estimated that nearly one in four women have polycystic ovaries with about a quarter of these developing symptoms and having the PCO syndrome (PCOS). The commonest presentation is that of irregular menstruation associated with ovulation defects and difficulty conceiving. This is usually easily remedied by ovulation induction, initially with clomiphene citrate, maybe with metformin, and sometimes with gonadotrophins or ovarian cautery. The other reason for women seeking advice is due to the increased secretion of androgenic hormones resulting in acne, hirsutism weight gain and sometimes alopecia. These symptoms are much harder to treat, with the first line of therapy being diet and exercise. It has been recognised that the principal biochemical abnormality is insulin resistance, but the role of insulin sensitisers is not yet clear. Whilst diabetes is more common in women with PCOS, whether the condition is really a long-term health risk has not yet been conclusively proven. Further studies are required to determine whether insulin sensitisers are of any long-term benefit.

Postmenopausal women often seek medical advice because they suffer from one or more subtypes of sexual dysfunction. A variety of nonprescription, prescription and investigational products to treat female sexual dysfunction is available, but the evidence regarding the effects of these products on female sexual function is inconclusive. Individualized care is vital as each woman has specific needs that require personalized treatments.

Prior to recommending existing pharmacological treatment in women with sexual dysfunction, behavioral therapy should be sought. This therapy may help women overcome psychological barriers towards sexual activity, modify sexual behavior and subsequently improve sexual function. A secondary option is pharmacological therapy to treat underlying medical conditions. Hormone replacement therapy with estrogens improves vasomotor symptoms, vaginal dryness, dyspareunia and general well-being, yet in most women has little effect on libido. Testosterone replacement enhances sexual motivation and improves libido. Tibolone has estrogenic, progestagenic and androgenic properties and is effective in several subtypes of female sexual function. The results from clinical trials using sildenafil citrate (Viagra), dopamine agonists, peripheral nonselective alpha-blockers, phosphodiesterase type-5 inhibitors, as well as oxytocine, ginkgo biloba, caffeine and psychostimulants are inconclusive.

Future randomized, double-blind, placebo-controlled trials with appropriate target population, validated outcomes measures, bigger sample sizes and of longer duration are needed to assess treatment options in women with sexual dysfunction.

In spite of being an eminent procedure in the repertoire of gynaecological practice there is no consensus on the best way of performing a hysterectomy in any particular clinical situation. Vaginal hysterectomy (VH) is associated with lower morbidity; fewer complications; shorter hospital stay and convalescence in comparison to abdominal hysterectomy (AH). VH is also more cost effective in comparison to laparoscopically assisted vaginal hysterectomy (LAVH) as the latter is expensive in terms of operating time and cost of equipment. It should not follow, therefore, that less than one-third of all hysterectomies are being performed vaginally.

There are two main factors influencing the type of surgery offered to the patient, namely the patient characteristics and the experience and preference of individual surgeons. Patient characteristics such as nulliparity and the large fibroid uterus serve as relative contraindications to vaginal surgery and hence the more inexperienced surgeon would traditionally opt for the abdominal approach. Special procedures have been suggested, however, which enable VH to be successfully performed in these patients. By educating the surgeon and encouraging the implementation of these techniques, the rates of VH can be maximised in order to provide the most optimal and cost effective service to women.

Infection with human immunodeficiency virus (HIV) was once associated with a poor prognosis. Today, however, with the use of highly active anti-retroviral therapy, the condition has been reduced to no more than a chronic illness, infected people leading normal lives. In addition, infertility and obstetric treatment can be individualized to enable infected couples to conceive safely and give birth with a minimal risk of cross-infecting the baby. This supports the idea that HIV–serodiscordant couples desiring fertility treatment should be offered the full range of services available without discrimination. This chapter examines the approach to treatment when one of the partners is infected, the goal being to achieve fertility with minimal or no risk to the uninfected partner, the potential offspring or the managing team.