Nexplanon Subdermal Implant: Assessment of Sexual Profile, Metabolism, and Bleeding in a Cohort of Italian Women.

OBJECTIVES: To evaluate the impact on metabolism, bleeding, and sexual function of Nexplanon, a subdermal implant. STUDY DESIGN: We recruited women (n=101) receiving the Nexplanon implant at two university centers in Italy between 2011 and 2016 into this prospective, observational, multicenter research trial. Participants completed the Interview for Ratings of Sexual Function (IRSF) and the Female Sexual Function Index (FSFI) questionnaires before and 3 and 6 months after the implant was inserted. In addition, all blood parameters were assessed at these visits. All women were given a menstrual diary card and a pictorial blood assessment chart to record daily any vaginal bleeding. RESULTS: The studied metabolic parameters remained in the normal range, showing no alarming modifications: minimal statistical reductions (in aspartate aminotransferase, alanine aminotransferase, total cholesterol, triglycerides, and activated partial thromboplastin time) and increases (in glucose and prothrombin activity) were observed. Changes in IRSF score over 6 months showed a significant increase in pleasure, personal initiative, orgasm, intensity of orgasm, and satisfaction, and a significant decrease in anxiety and discomfort. Mean Body Mass Index decreased, and the weekly frequency of sexual intercourse increased. CONCLUSIONS: Nexplanon showed not only a lower metabolic and bleeding impact, but also important positive effects on sexual function. It expands the range of possibilities for women, 38 and couples, in the modern concepts of sexual and reproductive wellbeing.

The need for investigations to elucidate causes and effects of abnormal uterine bleeding.

This article describes a modern perspective on the basic investigations for abnormal uterine bleeding (AUB) in low-resource settings compared with a much more detailed approach for high-resource settings, bearing in mind issues of effectiveness and cost effectiveness. AUB includes any one or more of several symptoms, and it should be evaluated for the characteristics of the woman's specific bleeding pattern, her "complaint" and the presence of other symptoms (especially pain), the impact on several aspects of body functioning and lifestyle, and the underlying cause(s), especially cancer. Ideally, the evaluation is comprehensive, considering each of the potential etiological domains defined by the International Federation of Gynecology and Obstetrics PALM-COEIN system for the classification of causes. However, the detail of the questions and the extent of investigations will be significantly influenced by the technologies available and the time allotted for a consultation. In general, investigations should be performed only if they will make a material difference to the management approaches that can be offered. This should be an important consideration when a range of costly high-technology tests is accessible or when certain tests only have limited availability.

Ultrasound assessment of first-trimester bleeding.

OBJECTIVE: To assess the outcome (to the end of the first trimester) of pregnancies with vaginal bleeding and the influence of ultrasound-acquired information on care and cost of care. METHODS: A chart review was performed of 1,240 patients receiving care at an integrated medical center for threatened abortion from 1998-2000. Records from 715 patients with adequate follow-up data were reviewed and outcomes studied. Charges for outpatient and inpatient care were obtained from the data warehouse. RESULTS: Main findings include that on endovaginal ultrasonography, 44% of the pregnancies were viable, of which 86% continued to the end of the first trimester and that of the 33% of pregnancies that were nonviable, 74% successfully miscarried without intervention. Charges for the care varied significantly, based on outcome and choice of site of care. CONCLUSION: Endovaginal ultrasonography for the evaluation of early pregnancy bleeding has a significant effect on care decisions and costs. LEVEL OF EVIDENCE: II-3.

[Hysteroscopic ablation of the endometrium in cases of dysfunctional uterine bleeding--advantage of preparations including zoladex]. / Khisteroskopska ablatsiia na endometriuma pri disfunktsionalni matochni kruvotechniia--predimstva na podgotovkata sus Zoladeks.

Hysteroscopic endometrial ablation (HEA) is a new alternative for patients with dysfunctional uterine bleeding (DUB), resistant to medical treatment. The relatively thin endometrium is a big advantage at the time of operation. In this article the results of an initial series of hysteroscopic operations (HEA) are given--as a whole and depending on preoperative treatment with GnRH-agonist. Seventeen patients with DUB underwent HEA. Six of them were pretreated with Goserelin acetate (Zoladex 3.6 mg, Astra Zeneca) two subcutaneous application at 28 days interval. The other 11 women were operated in the early postmenstrual period without medical pretreatment. Comparison was made between the two groups regarding preoperative endometrial thickness, operative time, operative complications, duration of hospital stay, change of the menstrual pattern after 6 and 12 months. Results showed 41.2% achievement of persistent amenorrhoea in patients as a whole (62.7% in the Zoladex group and 27.2% in the untreated group). Better results in the patients with Zoladex pretreatment (shorter operative time, higher incidence of amenorrhoea, patient's higher evaluation of the operation) can be explained with the reduced endometrial thickness at the time procedure. The authors consider the hysteroscopic roller-ball endometrial ablation as an upto-date cost-effective method for treatment of DUB. The method is quick, with very low incidence of complications, easy toleration, immediately recovery of the patient and the only possibility for women with high anaesthesiologic and operative risk. Two depot-doses of Zoladex before hysteroscopy lead to better intra- and postoperative results.

Endometrial biopsy in DUB.

OBJECTIVE: To determine the incidence of abnormal endometrial histology in women with dysfunctional uterine bleeding and to evaluate the predictive value of risk factors for endometrial cancer in women with dysfunctional uterine bleeding (DUB). STUDY DESIGN: We conducted a retrospective review of 310 women with DUB who underwent endometrial biopsy. The risk factors for abnormal endometrial histology included menstrual cycle irregularity, diabetes, nulliparity, hypertension, weight > or = 100 kg and age > or = 40 years. The incidence of endometrial abnormalities was determined, and the predictive value of combinations of risk factors was assessed using stepwise logistic regression. RESULTS: Twenty-one patients (6.7%) had abnormal endometrial biopsies. Menstrual cycle irregularity (P = .0001), age > or = 40 years (p = .022) and hypertension (P = .058) were independently significant risk factors for abnormal endometrial histology. The probability of abnormal endometrial histology in a premenopausal woman with DUB whose cycle was regular was < 1%. The presence of menstrual cycle irregularity increased the probability of abnormal endometrial histology to 14.3%. CONCLUSION: The patient who presents with DUB and a history of menstrual cycle irregularity warrants an endometrial biopsy, regardless of age. The current clinical emphasis on age (especially > or = 40 years) as justification for endometrial biopsy is unwarranted in patients with DUB. More careful selection of patients for endometrial biopsy will mean that fewer women are unnecessarily exposed to the discomfort and risk of complications associated with endometrial biopsy.

State-of-the-art flexible hysteroscopy for office gynecologic evaluation.

STUDY OBJECTIVE: To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost. DESIGN: A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage. SETTING: Office-based hysteroscopy suite in the outpatient building of a tertiary institution. PATIENTS: Women referred to this institution for gynecologic evaluation between February 1992 and December 1993. INTERVENTION: Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block. MEASUREMENTS AND MAIN RESULTS: A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475. CONCLUSION: Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.