Additional low-pressure pulmonary recruitment for reducing post-laparoscopic shoulder pain in gynecologic laparoscopy: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of additional low-pressure pulmonary recruitment in reducing postoperative shoulder pain. METHODS: A double-blind randomized controlled trial was conducted at Srinagarind Hospital between May 2021 and October 2021. Forty patients who underwent laparoscopic gynecologic surgery were randomized into either an intervention group that received additional low-pressure pulmonary recruitment (30 cmH2O) (n=20) or a control group (n=20). Shoulder pain was evaluated using a numerical rating scale from 0 to 10, 24, and 48 hours after the operation. RESULTS: The mean±standard deviation of shoulder pain at 24 hours after the operation of both the intervention and control groups were 2.10±2.27 and 1.45±1.73 points, respectively. The shoulder pain at 48 hours after the operation of the intervention and control groups were 1.15±1.46 and 0.85±1.73 points, respectively. There were no statistical differences in the mean difference between the two groups at 24 and 48 hours after operation (P=0.49; 95% confidence interval [CI], -0.61 to 1.91 and P=1.00; 95% CI, -0.96 to 1.56, respectively). No statistically significant differences were observed in additional analgesic medications used in either group, such as intravenous morphine or oral acetaminophen. CONCLUSION: Additional low-pressure pulmonary recruitment to reduce shoulder pain after laparoscopic surgery for benign gynecologic diseases did not show a significant benefit compared to the control group, especially when administering postoperative around-the-clock analgesia.

Fractional CO2 laser treatment for women with stress predominant urinary incontinence: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: To evaluate the efficacy of vaginal CO2 laser in women with stress predominant urinary incontinence (SUI) compared with the sham treatment. METHODS: A randomized controlled trial with sham treatment was conducted between January 2019 and April 2021. Women with predominant SUI were recruited and randomized into two groups: the CO2 laser group (n = 29) and the sham group (n = 30). The International Consultation on Continence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was used to evaluate the efficacy at 3 months postoperatively. All participants in both groups were advised to perform pelvic floor muscle training (PFMT) after the intervention. RESULTS: A total of 59 women were studied. A total of 29 women were included in the CO2 laser group and 30 women were included in the sham group. The baseline scores of the ICIQ-UI SF were similar in both groups. A significant improvement in urinary incontinence scores was found in both groups 3 months after treatment (p < 0.001). However, there were no statistically significant differences between the two groups at 3 months (p = 0.8281). There were no changes in bladder neck descent or levator hiatal area immediately after intervention or 3 months after completion of treatment in either group. Most participants who received the active intervention reported mild vaginal pain during the procedure that resolved spontaneously at the end of treatment. CONCLUSIONS: Fractional CO2 laser treatment does not provide any benefit over the sham technique in alleviating SUI symptoms. The improvement in SUI symptoms in both groups might be related to PFMT. This study was registered with the Thai Clinical Trial Register (TCTR20190131004).

Effectiveness of vaginal estriol with lactobacilli on urinary symptoms in postmenopausal women: a randomized-controlled trial.

OBJECTIVE: The aim of this study was to compare the effects of a vaginal tablet containing estriol (0.03 mg) plus lactobacilli (E3/L) with placebo on lower urinary tract symptoms (LUTS) in postmenopausal women (PMW). METHODS: This randomized, double-blinded, placebo-controlled trial was conducted at Srinagarind Hospital in Khon Kaen, Thailand. PMW with at least one LUTS, such as frequency, nocturia, dysuria, urgency, or stress or urgency urinary incontinence, were recruited. Participants were randomly assigned to receive either an E3/L tablet or placebo, administered vaginally daily at bedtime for 2 weeks, then twice a week for another 2 weeks. Symptom severity score was assessed using a visual analog scale (VAS), and quality of life (QOL) was measured using the validated Thai version of the Incontinence Impact Questionnaire-Short Form. The primary outcome was proportion of the PMW with LUTS improvement. Secondary outcomes were symptom severity score, participant satisfaction, QOL, and adverse events. Relative risk and 95% confidence intervals (CIs) were calculated using the chi-square or Fisher's exact test. An independent-sample and paired t test were used to compare means. RESULTS: Thirty-eight participants in each group completed the study. The proportion of PMW whose symptoms improved (both in terms of most bothersome symptom and overall) did not differ significantly between the two groups. Relative risk was 1.00 (95% CI, 0.74-1.36) and 0.90 (95% CI, 0.71-1.15), respectively. There were no differences in symptom severity score, participant satisfaction, or QOL. CONCLUSIONS: A 1-month course of vaginal E3/L does not appear to improve LUTS in PMW.

Prophylactic antibiotics for preventing infection after continence surgery in women with stress urinary incontinence.

BACKGROUND: Surgical options for treating stress urinary incontinence (SUI) are usually explored after conservative interventions have failed. Surgeries fall into two categories: traditional techniques (open surgery) and minimally invasive procedures, such as laparoscopic procedures, midurethral sling and injections with urethral bulking agents. Postsurgery infections, such as infections of the surgical site or urinary tract, are common complications. To minimise the risk of postoperative bacterial infections, prophylactic antibiotics may be given before or during surgery.  OBJECTIVES: To assess the effects of prophylactic antibiotics for preventing infection following continence surgery in women with stress urinary incontinence.  SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov and WHO ICTRP; and handsearched journals and conference proceedings to 18 March 2021. We also searched the reference lists of relevant articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs assessing prophylactic antibiotics in women undergoing continence surgery to treat SUI. DATA COLLECTION AND ANALYSIS: Two review authors selected potentially eligible trials, extracted data and assessed risk of bias. We expressed results as risk ratios (RR) for dichotomous outcomes and as mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We identified one quasi-RCT and two RCTs, involving a total of 390 women. One study performed retropubic urethropexy surgery requiring a transverse suprapubic incision, while the other two studies performed midurethral sling surgery. It should be noted that none of the included studies clearly specified the timing of outcome assessment. We are very uncertain whether prophylactic antibiotics (cefazolin) have an effect on surgical site infections (RR 0.56, 95% CI 0.03 to 12.35; 2 studies, 85 women; very low-certainty evidence) or urinary tract infections or bacteriuria (RR 0.84, 95% CI 0.05 to 13.24; 2 studies, 85 women; very low-certainty evidence). The effect of prophylactic antibiotics (cefazolin) on febrile morbidity is also uncertain (RR 0.08, 95% CI 0.00 to 1.29; 2 studies, 85 women; very low-certainty evidence). We are very uncertain whether prophylactic antibiotics (cefazolin) have any effect on mesh exposure (RR 0.32, 95% CI 0.01 to 7.61; 1 study, 59 women; very low-certainty evidence). None of the three included studies described the assessment of adverse events from antibiotic use, sepsis or bacteraemia in their reports. AUTHORS' CONCLUSIONS: Only limited data are available from the three included studies and, overall, the certainty of evidence was very low. Moreover, the three included studies evaluated different surgical procedures and dosages of antibiotic administration. Thus, there is insufficient evidence to support or refute the use of prophylactic antibiotics to prevent infection following anti-incontinence surgery. In addition, there were no data regarding adverse effects of prophylactic antibiotics. More RCTs are required.

A Cross-Sectional Study on the Quality of Life in Women with Endometrioma.

PURPOSE: To evaluate the quality of life (QoL) of women with endometrioma and explore the associated factors. PATIENTS AND METHODS: A cross-sectional study was conducted between August 2020 and March 2021. A total of 99 women diagnosed with ovarian endometrioma with at least one endometriosis-associated symptom completed the Endometriosis Health Profile 30 (EHP-30) questionnaire for their QoL score before treatment for ovarian endometrioma. The questionnaire comprises a central questionnaire (30 items) and a modular questionnaire (23 items divided into 6 sections). Demographics and QoL scores were analyzed using descriptive statistics and multivariable linear regression or median regression. RESULTS: The mean QoL score was 35.0±15.8 (range, 16.0±21.2 in the social support dimension to 45.1±24.4 in the control and powerlessness dimension). In the modular questionnaire, the highest score was in the infertility domain, while the lowest was in the relationship with the physician domain. The pain score and chronic pelvic pain (CPP) were independent correlation factors for a higher total EHP-30 score: the higher the total EHP-30, the poorer the QoL. CPP was positively correlated with the QoL score in the work domain. CONCLUSION: The present study revealed that CPP was the factor associated with a worse QoL and work performance in women with endometrioma based on a disease-specific, EHP-30 questionnaire.

Postoperative interventions for preventing bladder dysfunction after radical hysterectomy in women with early-stage cervical cancer.

BACKGROUND: Bladder dysfunction is a common complication following radical hysterectomy, caused by the damage to pelvic autonomic nerves that innervate the muscles of the bladder, urethral sphincter, and pelvic floor fasciae. Bladder dysfunction increases the rates of urinary tract infection, hospital visits or admission, and patient dissatisfaction. In addition, bladder dysfunction can also negatively impact patient quality of life (QoL). Several postoperative interventions have been proposed to prevent bladder dysfunction following radical hysterectomy. To our knowledge, there has been no systematic review evaluating the effectiveness and safety of these interventions for preventing bladder dysfunction following radical hysterectomy in women with cervical cancer. OBJECTIVES: To evaluate the effectiveness and safety of postoperative interventions for preventing bladder dysfunction following radical hysterectomy in women with early-stage cervical cancer (stage IA2 to IIA2). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to April week 2, 2020), and Embase via Ovid (1980 to 2020, week 16). We also checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of any type of postoperative interventions for preventing bladder dysfunction following a radical hysterectomy in women with stage IA2 to IIA2 cervical cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgments on the quality and certainty of the evidence. We resolved any disagreements through discussion or consultation with a third review author. Outcomes of interest consisted of spontaneous voiding recovery one week after the operation, quality of life (QoL), adverse events, post-void residual urine volume one month after the operation, urinary tract infection over the one month following the operation, and subjective urinary symptoms. MAIN RESULTS: We identified 1464 records as a result of the search (excluding duplicates). Of the 20 records that potentially met the review criteria, we included five reports of four studies. Most of the studies had unclear risks of selection and reporting biases. Of the four studies, one compared bethanechol versus placebo and three studies compared suprapubic catheterisation with intermittent self-catheterisation. We identified two ongoing studies. Bethanechol versus placebo The study reported no information on the rate of spontaneous voiding recovery at one week following the operation, QoL, adverse events, urinary tract infection in the first month after surgery, and subjective urinary symptoms for this comparison. The volume of post-void residual urine, assessed at one month after surgery, among women receiving bethanechol was lower than those in the placebo group (mean difference (MD) -37.4 mL, 95% confidence interval (CI) -60.35 to -14.45; one study, 39 participants; very-low certainty evidence). Suprapubic catheterisation versus intermittent self-catheterisation The studies reported no information on the rate of spontaneous voiding recovery at one week and post-void residual urine volume at one month following the operation for this comparison. There was no difference in risks of acute complication (risk ratio (RR) 0.77, 95% CI 0.24 to 2.49; one study, 71 participants; very low certainty evidence) and urinary tract infections during the first month after surgery (RR 0.77, 95% CI 0.53 to 1.13; two studies, 95 participants; very- low certainty evidence) between participants who underwent suprapubic catheterisation and those who underwent intermittent self-catheterisation. Available data were insufficient to calculate the relative measures of the effect of interventions on QoL and subjective urinary symptoms. AUTHORS' CONCLUSIONS: None of the included studies reported rate of spontaneous voiding recovery one week after surgery, time to a post-void residual volume of urine of 50 mL or less, or post-void residual urine volume at 6 and 12 months after surgery, all of which are important outcomes for assessing postoperative bladder dysfunction. Limited evidence suggested that bethanechol may minimise the risk of bladder dysfunction after radical hysterectomy by lowering post-void residual urine volume. The certainty of this evidence, however, was very low. The effectiveness of different types of postoperative urinary catheterisation (suprapubic and intermittent self-catheterisation) remain unproven.

Extragastrointestinal stromal tumor in the rectovaginal septum associated with acute arterial occlusion.

Extragastrointestinal stromal tumors (EGISTs) arise from atypical sites, such as the omentum, mesentery, retroperitoneal space, urinary bladder, or rectovaginal septum, and account for fewer than 10% of gastrointestinal stromal tumors (GISTs). Most EGISTs are asymptomatic at the time of diagnosis, due to the fact that they rarely cause symptoms until they grow to greater than 10 cm in diameter. Common presenting symptoms are a feeling of vaginal fullness and increased urinary frequency. Cases described in previous reports have been treated with surgery with or without targeted therapy. Here we report an unusual case of an EGIST at the rectovaginal septum presenting with excessive vaginal bleeding and acute arterial occlusion. This rectovaginal mass was successfully removed using the abdominoperineal approach and did not require targeted therapy.

Knowledge, Attitude, and Practices (KAP) Survey Towards Pelvic Floor Muscle Training (PFMT) Among Pregnant Women.

OBJECTIVE: To assess knowledge, attitude, and practices (KAP) of pelvic floor muscle training (PFMT) among Thai pregnant women. PATIENTS AND METHODS: One hundred and ten Thai pregnant women who attended the antenatal clinic of a tertiary care hospital were recruited. They were classified as "aware" if they could recognize PFMT. Questionnaires regarding the participants' attitudes and practice toward PFMT were subsequently collected from "aware" group. RESULTS: The mean ±SD of age and gestational age were 30.5 ±5.4 years and 20.8 ±10.8 weeks, respectively. Sixty-one participants (55.5%) recognized PFMT, but only seventeen (27.9%) correctly answered all of the questions, which is classified as perceptive. There was no association between their educational level and PFMT knowledge (p = 0.63). Most of them (98.4%) understood that PFMT can be performed during pregnancy and believed that PFMT did not affect the pregnancy outcomes. However, only 10.7% of the aware women performed PFMT irregularly during pregnancy. CONCLUSION: Half of the pregnant women in this study were aware of PFMT. The majority of women felt that PFMT had positive effects on their health, emotions, sex, and quality of life. Education concerning PFMT and motivation to maintain the adherence of practicing the exercises are required.

Bladder Safety during Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in the Patients with Extensive Vesicouterine Adhesion.

Adhesion at the vesicouterine fold presents a great challenge when performing hysterectomy through transvaginal natural orifice transluminal endoscopy surgery (NOTES) in women with a history of cesarean section. An attempt to lyse adhesions often prolongs the procedure and may inadvertently result in cystostomy. The purpose of this report is to demonstrate a safe technique for the lysis of vesicouterine adhesions during NOTES hysterectomy. We present the cases of two patients with a history of cesarean section. Severe adhesions at the vesicouterine peritoneum were encountered in both cases, and one patient had an extensive adhesion involving lower half of the uterus. Although the lateral approach is sufficient in most cases, it does not allow a surgeon to approach the peritoneal cavity if there is extensive adhesion. In cases such as these, direct dissection of the adhesion on the uterus is required.

The outcomes of transvaginal NOTES hysterectomy in various uterine sizes.

OBJECTIVES: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique in the area of minimally invasive procedures. Preliminary reports have confirmed transvaginal NOTES to be a safe and feasible method for performing hysterectomy and adnexal procedures. However, there are limitations regarding the feasibility of performing transvaginal NOTES hysterectomy in various uterine sizes. MATERIALS AND METHODS: Two hundred and seventy-five women who had undergone transvaginal NOTES hysterectomy for benign pelvic lesions were recruited from May 2012 to May 2016. Their medical records were retrospectively reviewed. All patients were placed into one of three groups depending on weight of the surgical specimen in order to assess surgical outcomes. RESULTS: One hundred ninety-one patients (69.46%) had a uterine weight of <500 g (group 1), 67 (24.36%) had a uterine weight of 500-999 g. (group 2), and 17 (6.18%) had a uterine weight of ≥1000 g. (group 3). The mean age± SD of group 1, group 2, and group 3 were 48.68 ± 6.63, 47.22 ± 3.81, and 46.53 ± 2.96 years, respectively (p value = 0.110). There was no statistical differences in terms of parity, body mass index (BMI), or history of abdominal surgery among the three groups. With regard to surgical outcomes, the mean operative times (Standard error: SE) were 76.70 (0.68), 99.99 (1.14), and 152.88 (3.37) minutes in Group 1, Group 2, and Group 3, respectively. The mean amounts of blood loss (SE) was 180.85 (4.61), 342.57 (6.98), and 532.35 (11.85) ml in Group 1, 2, and 3, respectively. There were statistically significant differences in terms of operative time and blood loss among the three groups (p = 0.0001 and 0.0001, respectively). CONCLUSIONS: Although the size of uterus has a significant effect on operative time and blood loss, NOTES hysterectomy can be successfully performed without any increase in complication rates. Natural orifice transluminal endoscopic surgery hysterectomy is a safe and feasible procedure even in large uteri.

An Elongated Endometrial Polyp Prolapsing Through the Introitus in a Virgin.

The objective of the study is to report on the unusual case of an elongated endometrial polyp prolapsing through the introitus. A nulliparous 38-year-old woman presented to the gynecology department with an abnormal mass prolapsing at the vulva area without any abnormal uterine bleeding. Because she had no history of having engaged in sexual intercourse, a pelvic examination was not performed. Ultrasonography revealed an intrauterine hyperechoic lesion 1.5 cm × 0.8 cm in diameter suspected to be endometrial polyp. A hysteroscopy revealed an elongated endometrial polyp 12 cm × 0.5 cm in length, which originated from the midanterior corpus and extended out of the cervix and introitus. Then, the base of the polyp was cut and removed. The pathological report was consistent with an endometrial polyp. This was an unusual case of an elongated endometrial polyp prolapsing through the introitus in a nulliparous woman. Hysteroscopy is the best tool for diagnosis and management in this case.

Discontinuation rate and adverse events after 1 year of vaginal pessary use in women with pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: To ascertain the rate of discontinuation after vaginal pessary use among pelvic organ prolapse patients. METHODS: We enrolled women suffering from pelvic organ prolapse who opted to use vaginal pessary as the first line of treatment and were fitted with a pessary at the urogynecological clinic in Khon Kaen University's Srinagarind Hospital (Thailand) during the period between 2010 and 2016. Patients' medical records were retrospectively reviewed. Patients were contacted by telephone if there were missing data or if more information was required. RESULTS: One hundred and forty women were included. The median age was 71.5 years (interquartile = 65.0, 77.0) and normal vaginal parity was 4.0 (interquartile =3.0, 6.0). The mean ± SD of BMI was 23.5± 3.6 kg/m2. Most of the women enrolled in the study (97.9%) were postmenopausal and many were at an advanced stage of prolapse (73.6%). Support pessaries were the most common treatment (95.0%). The discontinuation rate of pessary use after 1 year was 16.1%. The most common reason for discontinuing the vaginal pessary was frequent expulsion (26.3%). Abnormal vaginal discharge was the most common adverse effect after pessary insertion (17.1%). Lower BMI and history of hysterectomy were the significant risk factors for discontinuation of pessary use (0.76 [95%CI 0.62-0.93] and 15.89 [95%CI 1.67-151.02] respectively). CONCLUSIONS: The discontinuation rate of pessary use in the case of pelvic organ prolapse was low after 1 year. Abnormal vaginal discharge was the most common adverse side effect. Lower BMI and history of hysterectomy were factors significantly associated with the discontinuation.

Correlations of third-trimester hiatal biometry obtained using four-dimensional translabial ultrasonography with the delivery route in nulliparous pregnant women.

PURPOSE: The goal of this study was to evaluate normal hiatal dimensions in the third trimester in nulliparous Thai pregnant women and to establish which biometric factors were associated with various pregnancy outcomes. METHODS: Fifty-seven consecutive nulliparous pregnant Thai women in their third trimester were recruited on a voluntary basis from April to October 2014. All subjects underwent four-dimensional (4D) translabial ultrasonography. Hiatal biometric parameters were measured at rest, while performing a Valsalva maneuver, and during contraction. Information about the patients' eventual deliveries was obtained from their medical records. RESULTS: The mean values of the patients' age, body mass index, and gestational age at the time of examination were 27.4±5.47 years, 26.7±3.48 kg/m(2), and 36.6±1.49 weeks, respectively. No subjects had vaginal lumps or experienced prolapse greater than stage 1 of the Pelvic Organ Prolapse Quantification system. Ultrasonography showed that the mean values of the hiatal area at rest, while performing a Valsalva maneuver, and during contraction were 13.10±2.92 cm(2), 17.50±4.81 cm(2), and 9.69±2.09 cm(2), respectively. The hiatal area at rest, the axial measurement at rest, and the axial measurement while performing a Valsalva maneuver were significantly associated with the route of delivery (P=0.02, P=0.04, and P=0.03, respectively). CONCLUSION: The route of delivery was associated with hiatal biometric values measured using 4D translabial ultrasonography, based on the results of nulliparous Thai women in the third trimester.

Obstetrics anal sphincter injury and repair technique: a review.

The Urogynecology Committee of the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) has held seminars and workshops on various urogynecological problems in each country in the Asia-Oceania area in order to encourage young obstetricians and gynecologists. In 2013, we organized the operative seminar for obstetrical anal sphincter injuries (OASIS) in which we prepared porcine models to educate young physicians in a hands-on workshop at the 23rd Asian and Oceanic Congress of Obstetrics and Gynaecology in Bangkok, Thailand. Laceration of the anal sphincter mostly occurs during vaginal delivery and it can develop into anal sphincter deficiency, which causes fecal incontinence, if an appropriate suture is not performed. OASIS has become an important issue, especially in developing countries. The prevalence of OASIS of more than the third degree is around 5% in primary parous women and the frequency is higher when detected by ultrasonographic evaluation. Several risk factors, such as macrosomia, instrumental labor, perineal episiotomy and high maternal age, have been recognized. In a society where pregnant women are getting older, OASIS is becoming a more serious issue. An intrapartum primary appropriate stitch is important, but the 1-year outcome of a delayed operation after 2 weeks postpartum is similar. A randomized controlled study showed that overlapping suture of the external sphincter is better than that of end-to-end surgical repair. The Urogynecology Committee of the AOFOG would like to continue with educative programs about the appropriate therapy for OASIS.

Incidence of and risk factors for febrile morbidity after laparoscopic-assisted vaginal hysterectomy.

BACKGROUND: The purpose of this study was to assess the incidence of and risk factors for postoperative febrile morbidity after laparoscopic-assisted vaginal hysterectomy (LAVH). METHODS: This retrospective study was carried out using the medical records of women with benign gynecologic conditions who underwent LAVH between June 2007 and May 2012 at Srinagarind Hospital in Thailand. Data were collected to assess baseline patient characteristics, occurrence of body temperature ≥38°C on two occasions at least 6 hours apart in the 24 hours following the surgical procedure, and possible risk factors related to postoperative febrile morbidity. RESULTS: In total, 199 women underwent LAVH during the study period. They had a mean age of 46±6 years, a mean body mass index of 24.0±3.2 kg/m(2), a mean surgical duration of 134±52 minutes, median estimated blood loss of 200 mL, a mean total hospital stay of 5±2 days, and a mean postoperative hospital stay of 3±2 days. Postoperative febrile morbidity was documented in 31 cases (15.6%). The cause of postoperative fever was unknown in most cases, with only two cases having an identifiable cause. The risk of postoperative febrile morbidity was highest in women treated with more than two antibacterial agents and with a regimen of more than 3 days. CONCLUSION: This study shows a moderately high rate of febrile morbidity after LAVH, for which the main risk factors were use of multiple drugs and doses for antibiotic prophylaxis.

Effects of the levonorgestrel-releasing intrauterine system plus estrogen therapy in perimenopausal and postmenopausal women: systematic review and meta-analysis.

OBJECTIVE: The objective of this study was to compare the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) with those of systemic progestogen in perimenopausal and postmenopausal women taking systemic estrogen therapy (ET). METHODS: We searched Medline (August 8, 2009), Embase (August 8, 2009), the Cochrane Central Register of Controlled Trials on the Cochrane Library Issue 3 (2009), the MetaRegister of Controlled Trials, and the reference lists of articles for relevant trials. Randomized controlled studies of LNG-IUS versus systemic progestogen in perimenopausal and postmenopausal women taking ET were included in the review. Two reviewers abstracted the trials independently. Any disagreement was resolved through discussion with the third reviewer. For dichotomous outcomes, a Peto odds ratio was calculated. For continuous outcomes, nonskewed data from valid scales were synthesized using a weighted mean difference or a standardized mean difference. RESULTS: Six trials with a total of 518 participants were included. The methodological limitation was an attrition bias. In perimenopausal and postmenopausal women taking ET, the incidence of a proliferative endometrium was comparable between the use of systemic progestogen and LNG-IUS, except for sequential medroxyprogesterone acetate, which had a higher incidence of proliferative endometrium. Descriptive data synthesis showed that ET combined with either LNG-IUS or systemic progestogen effectively relieved climacteric symptoms. Vaginal bleeding and spotting were common in the LNG-IUS group for the first 3 to 6 months of use. The discontinuation rate was not different. There was insufficient evidence to draw any conclusions about the other outcomes. CONCLUSIONS: The LNG-IUS was more effective than sequential medroxyprogesterone acetate but was comparable with other systemic progestogen regimens for endometrial protection in perimenopausal and postmenopausal women taking ET.

Tuberculosis at vulva and vagina.

A 60- year-old woman, gravid 4, para 4-0-0-4 was admitted to the Department of Obstetrics and Gynecology, Khon Kaen University due to chronic extensive painful genital ulcer. She was treated by antiviral and antifungal regimens but the ulcer persisted. After acid fast bacilli was found on tissue biopsy, a standard 6- month course of antituberculosis was started. One month after treatment, the ulcer was completely cured.