Differential response to antidepressants in women with premenstrual syndrome/premenstrual dysphoric disorder: a randomized controlled trial.

BACKGROUND: Studies show that selective serotonin reuptake inhibitors are effective for severe premenstrual syndrome and premenstrual dysphoric disorder. This study compares the efficacy of a selective serotonin reuptake inhibitor with that of a tricyclic antidepressant to determine whether efficacy for premenstrual syndrome/premenstrual dysphoric disorder is a general or more serotonergic effect of antidepressants. METHODS: After 3 screening months, 189 subjects were randomized to sertraline hydrochloride, desipramine hydrochloride, or placebo for 3 months of double-blind treatment. The flexible dosage range was 50 to 150 mg/d. The outcome measures included the Penn Daily Symptom Report (DSR), the Hamilton Depression Rating Scale, the Clinical Global Impressions-Severity Scale, the Quality of Life Scale, and Patient Global Ratings of Functioning and Improvement. Analyses included all subjects with treatment data, with the last observation carried forward. RESULTS: Sertraline was significantly more effective than placebo or desipramine; desipramine was not better than placebo (F2,163 = 12.47, P<.001). All DSR factors were more improved with sertraline compared with desipramine and placebo; the factors for mood (P<.001) and pain (P = .05) were significant, and the results of all outcome measures were consistent. A history of depression, postmenstrual symptom levels, and other diagnostic variables added individually as covariates did not alter the treatment results. At end point analysis, DSR symptoms had decreased by more than 50% in 40 subjects (65%) in the sertraline group, 18 subjects (36%) in the desipramine group, and 16 subjects (29%) in the placebo group (P<.001). CONCLUSIONS: The comparison of 2 classes of antidepressants strongly favored the serotonergic drug, which effectively reduced symptoms and improved functioning and was well tolerated by women with severe premenstrual syndrome. A history of depression did not alter the treatment results.

Course of premenstrual syndrome symptom severity after treatment.

OBJECTIVE: Patients from a randomized, double-blind, placebo-controlled study of progesterone suppository treatment for premenstrual syndrome (PMS) were followed up to determine poststudy PMS symptom levels and medication use. METHOD: An average of 1 year after the end of the treatment study, 129 subjects were contacted for telephone interviews. All subjects met criteria for PMS before the progesterone suppository treatment, and their symptoms were confirmed by daily symptom reports throughout the study. The outcome measure at follow-up was the patient's global assessment of symptom severity, which was also rated by the subjects during the treatment study. The ratings at enrollment, end of study, and follow-up were compared. RESULTS: Only 27% of the subjects (N = 35) were taking medications for PMS at follow-up. Symptom severity at follow-up was less than at enrollment but greater than at the end of the study. CONCLUSIONS: Some of the improvement gained during treatment was maintained, but overall the subjects remained moderately symptomatic. Validation of the PMS condition, education, and support and caring may account for the symptom decreases during treatment, and the end of treatment and withdrawal of these conditions may account for the moderate return of symptoms.

Update on the metabolic effects of steroidal contraceptives.

Modern oral contraceptive pills are safe and show minimal metabolic effects that have little clinical significance to smoking and reproductive age (even up to menopause). Multiphasic and 30 to 35 micrograms EE fixed combination pills are preferable to higher dose EE pills. Triphasic pills with norgestrel or norethindrone, monophasic norethindrone pills, and combination pills with the newer progestins are all probably metabolically comparable. The levonorgestrel implant is convenient, reversible, and effective and eliminates estrogenic metabolic effects. Metabolic benefits of the pill may include less acne, better preservation of bone mass, and less blood loss. Women who smoke should be encouraged to stop. Women with risk factors for atherosclerosis such as smoking, lipid abnormalities, diabetes, or hypertension should avoid combination pills. Women with a history of pregnancy, steroid-related thrombophlebitis, or thromboembolic disease should not use estrogen-containing pills.

PIP: In the past 30 years mortality from coronary artery disease has decreased in the United States. From 1968 to 1976 it went down from 16.3 deaths among women aged 35-40 to 11.1 deaths/100,000 populations. Among women aged 45-54 the rate decreased from 72.8 to 56.5/100,000. A 1979 study examined the effect of combined oral contraceptives (OCs) on blood lipids in 1500 women using levonorgestrel or LNG pills (150-250 mcg monophasic and 50-75-125 triphasic), norethindrone (.5-1 mg) pills with 30-40 mcg of ethinyl estradiol (EE), and progestin-only preparations. The combination OCs increased triglycerides by 13-75% while progestins did not increase them. Total cholesterol did not change: LDL and HDL II decreased slightly. Another study, the Triphasic Randomized Clinical Trial (TRACT) probe, included 150 women using triphasic OCs: 35 mcg of norethindrone; 30-40-30 mcg of EE, 50-75-125 mcg of norgestrel; or 24 mcg of E, 500-1000-500 mcg of norethindrone. LDL increased from 0 to 11% and HDL II decreased by 29-33% after 6 months of OC use. The rise in HDL and HDL II and fall of LDL was observed in a 1990 study of 150 mcg desogestrel and 30 mcg of EE (Marvelon). OCs with 250 mcg of LNG produced the greatest drop of HDL II. Higher dose OCs used before the 1990s increased glucose levels, plasma insulin levels (especially with norgestrel), and reduced glucose tolerance (particularly by 50 mcg of EE). OCs with 150 mcg of desogestrel and 30 mcg of EE slightly increased C-peptide levels, but insulin and glucose level increases were marked. Thromboembolitic changes via clotting factor alterations were similar after the use of OCs with 30-35 mcg EE, triphasics, or new progestins. LNG implants (Norplant) significantly reduced HDL cholesterol and slightly lowered HDL II, while somewhat increasing serum glucose and insulin.

Fluvoxamine for premenstrual dysphoric disorder: a pilot study.

BACKGROUND: Serotonergic agents appear to be effective treatments for premenstrual symptoms in a number of small trials. The purpose of this open-label treatment study was to collect pilot information on the efficacy of fluvoxamine for premenstrual dysphoric disorder (PDD). METHOD: Twelve women who sought medical treatment for premenstrual symptoms were evaluated. The main outcome measure was the premenstrual score from daily symptom reports (DSRs) maintained by the subjects. After a 2-month screening period, 10 subjects who met DSM-IV criteria for PDD were treated with fluvoxamine taken daily for two menstrual cycles. The mean dose at 4 weeks was 85 mg/day; at 8 weeks, all subjects took 100 mg/day. RESULTS: The mean premenstrual DSR scores improved at 4 weeks from the pretreatment baseline (paired t test, p < .0008) and remained improved at 8 weeks at approximately the same level (p < .003). Symptoms with the greatest improvement (p < .003, significant with the Bonferroni adjustment) were irritability, anxiety, feeling out of control, and decreased interest in usual activity. Sixty percent (6/10) of the subjects reported at least a 50% reduction in the DSR scores, a conservative clinical definition of improvement. The mean premenstrual Hamilton Rating Scale for Depression scores decreased from 19 at the pretreatment baseline to 9 at the 4-week evaluation. The main side effects were insomnia (N = 6), fatigue (N = 4), dry mouth (N = 4), and nausea (N = 3) and were generally mild and transient. CONCLUSION: These promising pilot data show the importance of a controlled trial over a longer time period to provide definitive information on the efficacy of fluvoxamine for premenstrual dysphoric disorder.

Predictors of response to sertraline treatment of severe premenstrual syndromes.

BACKGROUND: Serotonergic antidepressant medications have demonstrated efficacy in the treatment of severe premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Over 60% of subjects responded well to sertraline treatment for PMS and PMDD in double-blind controlled studies. However, no studies have evaluated the predictors of treatment response for this disorder. The current study examined pretreatment demographic, medical history, and clinical symptom predictors of sertraline response in PMS and PMDD treatment. METHOD: Sixty-two subjects diagnosed with severe PMS (according to the Daily Symptom Report and global ratings of functional impairment) or PMDD (DSM-IV) received sertraline treatment as part of a randomized, double-blind, placebo-controlled treatment efficacy study. All subjects completed 3 screening cycles, including a single-blind placebo washout cycle, prior to 3 cycles of double-blind treatment. Outcome was assessed across the domains of PMS symptoms and quality of life. Demographic, medical history, and symptom variables were used to predict sertraline response. RESULTS: Baseline postmenstrual symptom ratings were significantly and independently associated with posttreatment PMS symptoms in multivariate analysis. Premenstrual and postmenstrual ratings of depression, medical history variables, and demographic variables were not significantly predictive of response to sertraline. CONCLUSION: Baseline postmenstrual symptom ratings controlled for baseline premenstrual symptoms were associated with PMS symptoms at sertraline treatment endpoint. The findings suggest that nonmenstrual-related baseline characteristics other than depression may influence sertraline treatment outcome in patients with higher postmenstrual symptom levels.

Gonadotropin-releasing hormone agonist in treatment of premenstrual symptoms with and without comorbidity of depression: a pilot study.

BACKGROUND: Gonadotropin-releasing hormone agonist (GnRHa) in depot form for once-a-month rather than daily injection was examined in a small open trial to determine the extent of reduction of premenstrual symptoms, particularly premenstrual "depression." METHOD: Women who met criteria for premenstrual syndrome (PMS) or for PMS with comorbidity of major depression (MD), based on DSM-III-R criteria, were evaluated for the study. Evaluation included Structured Clinical Interview for DSM-III-R, administered in the follicular phase, and Daily Symptom Report (DSR), maintained throughout the study. Seven PMS subjects and two subjects who met the severity and change criteria for PMS but had concurrent MD were administered 3.75 mg of depot leuprolide monthly. Symptom change as reported on the DSR was compared with the untreated baseline scores. RESULTS: Six of seven PMS subjects had cessation of menses and significant decreases in premenstrual symptoms (p < .0001), which were reduced to their follicular phase levels. Physical symptoms of swelling and breast tenderness were among the most improved symptoms. Despite cessation of menses, the two MD subjects showed little improvement in premenstrual symptoms and no improvement in depressive symptoms. The premenstrual depression scores decreased almost completely in the PMS subjects, but increased slightly in the MD subjects. CONCLUSION: This small open trial suggests that GnRH agonist therapy reduces premenstrual symptoms including "depression" in women who meet criteria for PMS but not in women with PMS and MD. Further controlled study of the role of ovarian function in mood disorders is needed.

Sertraline versus desipramine in the treatment of premenstrual syndrome: an open-label trial.

BACKGROUND: Antidepressant medications have appeared to be effective treatments for premenstrual syndrome (PMS) in several small trials. This open-label study examined the efficacy of and tolerance for a new serotonergic antidepressant compared with a traditional tricyclic antidepressant in PMS treatment. METHOD: For two menstrual cycles in women meeting well-defined criteria for PMS, an open-label comparison of the serotonin selective sertraline (N = 17) and the noradrenergic desipramine (N = 15) was performed. Dose was flexible, with a mean dose in the second cycle of 87 mg/day for sertraline and 110 mg/day for desipramine. Outcome measures were the premenstrual daily symptom report (DSR) scores and the Hamilton Rating Scale for Depression (HAM-D). RESULTS: Sertraline and desipramine reduced depressive symptoms as assessed by the HAM-D, both achieving similar reductions in the HAM-D scores. Reduction of total premenstrual symptoms as assessed by the DSR score was observably greater with sertraline, but the difference compared with desipramine was not statistically significant in this small sample. Subjects were more likely to perceive desipramine side effects as intolerable; 4 of the 15 desipramine-treated subjects discontinued compared with none in the sertraline group. Subjects who were previously treated in a PMS program without good therapeutic response were less likely to respond to either medication, suggesting a treatment-resistant group. CONCLUSION: Sertraline and possibly desipramine appear to be effective treatments for PMS. Sertraline was better tolerated, resulting in greater patient acceptance. A placebo-controlled trial in which subjects are randomly assigned to the medication is clearly needed to support or refute these preliminary findings.

Detection of Neisseria gonorrhoeae in cervical swabs using the Gonozyme enzyme immunoassay. Clinical evaluation in a university family planning clinic.

The authors performed a prospective clinical evaluation of the Gonozyme (Abbott Laboratories, Chicago, IL) assay in a family planning clinic population. One thousand five hundred eighty-eight female patients were screened for gonococcal infection using culture and Gonozyme assay. One hundred nine patients were culture positive (6.9% disease prevalence). The sensitivity and specificity of the Gonozyme assay in this setting was 87.2% and 89.1%, respectively. The predictive value of a positive and negative test, given a disease prevalence of 6.9%, was 37.2% and 98.9%, respectively. The false-positive and false-negative rate was 10.9% and 12.8%, respectively. The authors prospectively followed patients with true-positive and false-positive Gonozyme results. The Gonozyme test showed a 83% correlation with test of cure cultures and, thus, should not be used for test cure analysis. False-positive Gonozyme tests could not be explained on the basis of cross-reacting bacteria or detection of vancomycin-sensitive gonococci. The authors' results suggest that the Gonozyme test should not be used in lieu of culture in a clinical setting with a similar population.

PIP: The authors performed a prospective, clinical evaluation of the Gonozyme assay in a family planning clinic population. 1588 female patients were screened for gonococcal infection using culture and Gonozyme assay. 109 patients were culture positive (6.9% disease prevalence). The sensitivity and specificity of the Gonozyme assay in this setting was 87.2% and 89.1% respectively. The predictive value of a positive and negative test, given a disease prevalence of 6.9%, was 37.2% and 98.9%, respectively. The false positive and false negative rate was 10.9% and 12.8% respectively. The authors prospectively followed patients with true positive and false positive Gonozyme results. The Gonozyme test showed an 83% correlation with test of cure cultures and, thus, should not be used for test of cure analysis. False positive Gonozyme tests could not be explained on the basis of cross-reacting bacteria or detection of vancomycin sensitive gonococci. Results suggest that the Gonozyme test should not be used in lieu of culture in a clinical setting with a similar population.

Effects of medical history factors on symptom severity in women meeting criteria for premenstrual syndrome.

Medical history variables were examined to identify their effects on the severity of premenstrual syndrome (PMS) in women seeking medical treatment. Symptoms were monitored daily for two untreated cycles and two placebo-treated cycles to establish the diagnosis of PMS. Data from 60 women who reported moderate to severe premenstrual mood changes and met criteria for PMS were analyzed statistically. Step regression analysis showed that 34% of the variance in symptom severity was explained by four variables: PMS in the patient's mother, low level of exercise, younger age, and more children. These significant relationships with severity of PMS have not previously been identified and suggest a role of familial and daily stress factors in this complex syndrome.

Ovulation prediction by monitoring salivary and vaginal electrical resistance with the PEAK Ovulation Predictor.

We investigated the ability of the PEAK Ovulation Predictor to predict the expected date of ovulation in 21 infertile, spontaneously ovulating women. A nonsignificant correlation (R = 0.15; P = .51) existed between the predicted date of ovulation and the day of the serum LH peak. A moderately strong correlation (R = 0.61; P less than .01) was observed between the day of the salivary electrical resistance peak and that of the serum LH peak. However, the serum LH peak occurred between 4-9 days after an identified peak in salivary electrical resistance. Twice-daily urine LH testing correlated strongly with both the serum LH peak (R = 0.93; P = .0001) and the ultrasound-detected day of ovulation (R = 0.81; P = .0001). A statistically significant peak in the mean salivary or vaginal electrical resistance on a particular day relative to the day of the serum LH peak could not be demonstrated. When identified, the nadir in vaginal electrical resistance occurred no earlier than 2 days before the serum LH peak and thus may mark the endpoint of the fertile period for natural family planning methods. We conclude that, whereas the PEAK Ovulation Predictor is of little value in accurately predicting ovulation, measurements of salivary and vaginal electrical resistance may be helpful in timing inseminations. However, for detection of the serum LH surge, twice-daily urine LH testing demonstrated a stronger correlation and narrower frequency distribution than did those determinations based on electrical resistance.

Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.

OBJECTIVE: To compare rates of method continuation and repeat pregnancy among postpartum adolescents selecting depot medroxyprogesterone acetate or oral contraceptives (OCs). METHODS: A retrospective study of 161 adolescents aged 19 years and younger who gave birth at an urban teaching hospital between May 1, 1994, and April 30, 1995, returned to the hospital's family planning clinic within 14 weeks of delivery and chose depot medroxyprogesterone acetate (n=111, 69%), or OC (n=50, 31%) as their postpartum contraceptive method. Most subjects were black (99%), single (97%), and on medical assistance (85%). Data were gathered 12-18 months postpartum (mean+/-standard deviation [SD] 14.5+/-1.6 months) by telephone interview and medical record review. The main outcome measures were method continuation and repeat pregnancy. RESULTS: The mean (+/-SD) age at delivery was 17.8+/-1.4 years. Variables differentiating subjects selecting depot medroxyprogesterone acetate or OC included multiparity (34% versus 12%, P < .05), mean age at first pregnancy (15.9 versus 16.6 years, P < .05), and mean age at first delivery (16.1 versus 16.9 years, P < .05). The survival curves for depot medroxyprogesterone acetate and OC continuation differed significantly (median duration of use 8.1 versus 5.4 months, respectively), but the continuation rates at 12 months were similar (34% versus 32%). The survival curves for repeat pregnancy among subjects selecting depot medroxyprogesterone acetate differed significantly from curves of those choosing OC, with repeat pregnancy rates of 15% and 36% by 15 months. Postpartum selection of OC was the only variable entering a Cox regression model designed to predict repeat pregnancy (relative risk 3.0, 95% confidence interval 1.4, 6.7). CONCLUSION: Adolescent mothers choosing depot medroxyprogesterone acetate or OC immediately postpartum face similarly high rates of method discontinuation and repeat pregnancy within 1 year.

Complications of female sterilization: immediate and delayed.

Surgical sterilization in women has changed dramatically over the past 20 years. The development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. In the United States, changing social values and changes in hospital regulations have done as much as technology to account for the tremendous increases in the number of women undergoing sterilization. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Hysterectomy for sterilization alone carries unacceptable morbidity and mortality rates. Originally, laparoscopic techniques utilized unipolar cautery. However, bowel burns, a rare but serious complication, were reported, and this led to newer techniques. These techniques, using bands, clips, and bipolar cautery, have gained increasing popularity and have eliminated many of the serious complications of female sterilization. Historically, there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the subsequent gynecologic and psychologic problems called "post-tubal ligation syndrome." A review of earlier literature indicates that many of these studies have serious methodologic problems, including recall bias, inappropriate control groups, failure to elicit prior history of gynecologic or psychologic problems, and failure to account for the use of oral contraceptives or IUDs. More recent large prospective epidemiologic studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women. However, there are some data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Additional data from these ongoing large-scale studies and others should help to elucidate this problem in the future. Pregnancy after sterilization (even excluding pregnancies present at the time of the procedure) is more common the first year after the procedure with the risk decreasing in subsequent years.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: Surgical sterilization has changed dramatically over the past 20 years; the development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Historically there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the post-tubal ligation syndrome. More recent studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women, but there are data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Data from the Collaborative Review of Sterilization (CREST) conducted by the Centers for Disease Control from 1978-81 are analyzed. Overall complication rates were 42.8% for abdominal hysterectomy and 24.5% for the vaginal procedure. Postoperative febrile morbidity was the most common complication but 0.8% of the abdominal hysterectomies and 1.6% of the vaginal hysterectomies required repeat exploratory operations. In another series of 5018 women 0.45% had bleeding complications during unipolar cautery, 0.29% required laparotomy. In a series of 846 silastic ring sterilizations, 3.1% had bleeding complications but only 2 of these required laparotomy and 1.6% had complications related to the ring technique. It was also shown by the CREST data that: 1) the use of an IUD 1 month prior to sterilization did not alter the risk of complications, 2) sterilization and removal of an IUD should not be performed at the same time, and 3) the risk of requiring laparotomy to complete the sterilization procedure is greater if the woman has a history of previous abdominal or pelvic surgery or obesity greater than 12% of ideal body weight. Pregnancy after sterilization is more common the 1st year after the procedure with the risk decreasing in subsequent years. 1st-year failures are about 0.18-0.37/100 women years and then fall off to 0.1--0.12/100 woman years in subsequent years. The ratio of ectopic pregnancy among these pregnancies is higher after laparoscopic cautery techniques. Band and clips may be slightly less effective than the use of electrocoagulation or the Pomeroy technique. Resection is associated with a slightly higer risk of mesosalpingeal bleeding.

Serum progesterone levels following vaginal administration of progesterone during the luteal phase.

We measured serum progesterone (P) levels after administration of 400 mg P vaginal suppositories to women during the luteal phase of the menstrual cycle. Blood samples were obtained before suppository insertion and at five intervals up to 8 hours after insertion. On the first day of treatment with P suppositories, there was a substantial elevation in serum P above baseline after insertion. However, on subsequent days of administration a smaller increment in serum P was observed. In 4 women studied on days 1 and 8 of the same treatment cycle in the luteal phase, a smaller rise in serum P following suppository administration on day 8, compared with day 1, was found. Overall, a highly significant negative correlation between change in serum P from baseline and duration of vaginal suppository treatment was found. This observation does not appear to be related to the achievement of a pharmacokinetic steady state. Possible mechanisms for this observation are discussed.

Physiologic and psychologic profiles in a survey of women runners.

The purpose of the present study is to report physiologic and psychologic factors in a survey of women runners. Psychologic factors were used in an investigation of differences in perceived emotional distress within a group of women runners. The psychologic information was compared with the results of two groups of infertility patients and a group of fertile control subjects. Among the physiologic factors, there was a significant difference in the mean weight and the height/weight ratio between amenorrheic and regularly cycling runners (P less than 0.001) and amenorrheic runners and runners with irregular cycles (P less than 0.01). The psychologic data showed no difference between runners and fertile control subjects. When runners were divided according to menstrual intervals or miles run per week, there were differences in perceived emotional distress.

Simultaneous ectopic pregnancy with intrauterine twin gestations after in vitro fertilization and embryo transfer.

A simultaneous ectopic tubal pregnancy with viable intrauterine twin gestations after IVF-ET of five fertilized eggs is presented. Pelvic ultrasound and serial quantitative hCG levels were not helpful in the diagnosis of the tubal pregnancy. The risk of multiple pregnancies and of concomitant intrauterine and extrauterine gestations increases with transfer of a greater number of embryos. Karyotype of the tubal pregnancy was normal (46,XX).

A clinician's guide to the premenstrual syndrome.

Many women have menstrual symptoms, but relatively few have severe PMS. PMS is a well-defined premenstrual cluster of predominantly affective symptoms that disrupt a woman's daily functioning. PMS is diagnosed with prospective charting of symptoms and should be differentiated from nondisruptive menstrual symptoms, major affective disorders, and other common medical and gynecologic conditions. Most women with PMS can be helped. The serotonin reuptake inhibitors are becoming the first line of therapy for PMS because they are effective, easily tolerated, and free of major side effects. There is also evidence supporting the role of other antidepressants, anxiolytics, and GnRH agonists in the treatment of PMS. Although increasing control of one's life, promoting a healthy diet, the avoidance of salt and caffeine, vitamin supplementation, and exercise have not been proved as effective treatment for PMS, they should be promoted for their obvious general health benefits. No one treatment fits the heterogeneous PMS population. A trial of medication should be continued for two or three menstrual cycles with appropriate dose adjustments. If relief is not sufficient, other agents or other treatments should be initiated.

Premenstrual symptoms and dysmenorrhea in relation to emotional distress factors in adolescents.

The extent to which premenstrual symptoms occur when they are distinguished from primary dysmenorrhea and the relationship of premenstrual symptoms to other emotional distress in adolescents is not well understood. This pilot investigation examined relationships between premenstrual symptoms, dysmenorrhea and emotional distress factors in a sample of 165 females, ages 15-19 years. Premenstrual symptoms were correlated with dysmenorrhea (r = 0.54, p < 0.0001). Subjects with premenstrual symptoms had significantly more emotional distress than the normal group as assessed by the Symptom Checklist (SCL-90), an objective self-report questionnaire. In contrast, dysmenorrhea had no relationship with the SCL factors and no interaction with premenstrual symptoms in relation to emotional distress. The SCL scores significantly decreased from baseline (2 years earlier) in the normal group but not in the premenstrual symptom group. The data show that premenstrual symptoms were associated with other emotional distress factors in adolescents while dysmenorrhea was not. A further prospective, longitudinal study of menstrually-related symptoms in adolescents is needed to learn about the development of these premenstrual symptoms that may be related to the premenstrual syndrome seen clinically in the later reproductive years.

Influence of maternal attitudes on urban, black teens' decisions about abortion v delivery.

Two hundred thirty-one inner city black teenagers, aged 14-17, were followed for two years to assess whether (1) their decision to deliver or abort a pregnancy differed from their perceptions of their mothers' attitudes about having a child or aborting a pregnancy, (2) satisfaction with the decision differed between the abortion and delivery groups, and (3) satisfaction with the decision was affected by who made the decision. Eight-one percent chose the pregnancy outcome that their mothers supported. Those who did decide without their mothers' support (19%) were divided equally between abortion and continuing the pregnancy. The majority in both groups were satisfied with the outcome decision, but initially more deliverers than aborters were satisfied. Satisfaction initially was related to who made the decision, but by the one-year follow-up the difference was no longer significant. Young teens do not seem likely to make a decision about pregnancy outcome that differs from their mothers' views; initial differences in satisfaction with the decision disappear over a one- to two-year period.

PIP: 231 inner city US black teenagers, aged 14-17, were followed for 2 years to assess whether their decision to deliver or abort a pregnancy differed from their perceptions of their mothers' attitudes about having a child or aborting a pregnancy, whether satisfaction with the decision differed between the abortion and delivery groups, and whether satisfaction with the decision was affected by who made the decision. 62% of the teens--58% of those who delivered (the D group) and 65% of those who chose abortions (the A group)--indicated that their pregnancies were unwanted. 75% of the teens reported that the decision about the pregnancy outcome was made by themselves; 18% were made by mothers and 7% by others, usually the boyfriend. In the D group, 83% perceived their mothers as supporting their having a baby, while in the A group, 78% perceived their mothers as supporting abortion. Although most felt that they themselves had made the decision, the majority (81%) chose the pregnancy outcome that their mothers supported. Approximately 6 months after the decision about pregnancy, the majority in both groups were satisfied with their decision. The D group was more satisfied (88%) than the A group (73%). 1 year later this proportion was approximately the same; satisfaction increased for both groups after 2 years (95% of the D group and 88% in the A group). Initially, satisfaction was related to who made the decision. At 6 months, 78% of the teens who made their own decision as compared to 57% of those whose mother made the decision were satisfied. But as satisfaction increased over time, the greatest increase was among those whose mother made the decision. Satisfaction was not affected overall by whether the pregnancy was wanted or unwanted. Those teens who made their own decision were just as satisfied as those teens who had their mothers' support. Since the data indicates that young teenagers are not likely to make a decision about pregnancy that differs from their mothers' views, counseling should not focus on the teen alone but should include her mother as well.

Mortality following unilateral twin interstitial ectopic pregnancy. A case report.

Twin ectopic pregnancy is an uncommon event, usually occurring as simultaneous intrauterine and tubal gestations. Interstitial implantation of an ectopic pregnancy is also a rare event, associated with a high mortality rate. Twin interstitial pregnancy has been previously reported only three times in the English literature. We report a recent case of unilateral twin interstitial ectopic pregnancy that resulted in maternal death and review the literature with regard to both ectopic pregnancy and factors associated with mortality from interstitial implantation.

Torsion of the uterine adnexa. Pathologic correlations and current management trends.

OBJECTIVE: To evaluate the clinical and pathologic correlates of specimens removed for the diagnosis of adnexal torsion and to evaluate trends in the management of torsion. STUDY DESIGN: Cases of ovarian or adnexal torsion (N = 104) were identified retrospectively over a period extending from January 1987 to March 1998 by the coding of ovarian, fallopian tube or adnexal torsion. Statistical evaluation was by chi 2 analysis using the Bonferroni inequality correction when appropriate. RESULTS: Neoplastic and functional tumors of the ovary composed > 90% of the diagnoses at microscopic evaluation, with cancer diagnosed in < 1% of cases. Laparoscopy was attempted in 47 (46%) cases, and adnexasparing procedures were performed in 20 (19%) patients. Patients treated in the latter half of the study were not less likely to undergo laparotomy than those treated in the first half; however, conversion from laparoscopy to laparotomy was significantly less common in the latter half. Patients in this study were more likely to receive an adnexa-sparing operation than historical controls, but there was no improvement in this rate from the first to the second half of this study. A history of previous abdominal surgery was the most common associated condition, but 47% of patients had no known risk factors. Ovarian hyperstimulation, previously omitted in series reports, was an antecedent factor in 9% of patients. CONCLUSIONS: Adnexal torsion is most commonly associated with a benign process. A more-conservative approach to the treatment of this process is becoming increasingly common, as seems warranted in light of the low incidence of malignancy. The need for conversion from a laparoscopic to an open approach appears to have been waning over the last decade; that may correlate with an increased comfort level in gynecologists with laparoscopic approaches.