Dysphoric milk ejection reflex among Japanese mothers: a self-administered survey.

BACKGROUND: The dysphoric milk ejection reflex (D-MER) is a reflex that causes temporary discomfort during milk ejection. D-MER develops due to the effects of hormones involved in lactation, and it has been reported that it is a physiological symptom different from postpartum depression, but the actual situation is unknown in Japan. METHODS: This study was conducted using a self-administered, anonymous survey of mothers of children who had undergone health checkups at three years of age at five health centers in Kagoshima city and aimed to clarify the reality and perceptions of mothers regarding D-MER. The survey period was from May to September, 2022. The questionnaires were distributed to 389 mothers, and 216 (55.5% recovery rate) responses were received, of which 202 (valid response rate 93.5%) were included in the analysis. RESULTS: Regarding the experience of D-MER, 202 mothers in the study population had given birth to a total of 403 children and experienced D-MER when breastfeeding 62 children (15.4%). Of the 202 mothers included in the analysis, 47 (23.3%) answered that they had experienced D-MER with at least one child while breastfeeding. Sixty-six mothers (32.7%) knew about D-MER. Compared to those who had not experienced D-MER, those who had experienced D-MER had significantly higher scores on the items related to having had trouble breastfeeding (odds ratio (OR]: 3.78; 95% confidence interval (CI]: 1.57, 9.09) and knowing about D-MER (OR 2.41; 95% CI 1.20, 4.84). Regarding symptoms, irritability (n = 24, 51.1%), anxiety (n = 22, 46.8%), and sadness (n = 18, 38.3%) ranked high. Coping strategies included distraction, focusing on the child, and, in some cases, cessation of breastfeeding. Thirty mothers (63.8%) answered that they did not consult anyone, citing reasons such as a belief that no one would be likely to understand their symptoms, and that they could not sufficiently explain their symptoms. CONCLUSION: The low level of awareness of D-MER suggests that it is necessary to inform and educate mothers and the public about the physiological symptoms of D-MER. Moreover, it is necessary to listen to the feelings of mothers with D-MER and support them in coping with their symptoms.

Application of objective structured clinical examination (OSCE) for the evaluation of Kampo medicine training.

BACKGROUND: The purpose of this study was to develop an objective, content-valid, and reliable assessment method for Kampo medicine using an objective structured clinical examination (OSCE) for the assessment of clinical competence in Kampo medicine. METHODS: We developed a blueprint followed by a list of 47 assessment items and three task scenarios related to clinical competence in Kampo medicine. An eight-member test committee checked the relevance of the assessment items on a Likert scale. We calculated a content validity index and content validity ratio, and used the Angoff method to set the passing threshold. We trained a total of nine simulated patients with three assigned to each scenario. We conducted an OSCE for 11 candidates with varying medical abilities, and conducted three stations per person, which were evaluated by one evaluator in one room by direct observation. We used video recordings to test the inter-rater reliability of the three raters. We used the test results to verify the reliability of the assessment chart. RESULTS: The inter-rater reliability (intraclass correlation coefficient [2,1]) was 0.973. The reliability of the assessment chart for each scenario (Cronbach's α) was 0.86, 0.89, and 0.85 for Scenarios 1, 2, and 3, respectively. The reliability of the assessment chart for the whole OSCE (Cronbach's α) was 0.90. CONCLUSIONS: We developed a content-valid new OSCE assessment method for Kampo medicine and obtained high inter-rater and test reliabilities. Our findings suggest that this is one of the most reliable evaluation methods for assessing clinical competence in Kampo medicine.

Guideline for Gynecological Practice in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2020 edition.

Nine years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the 4th Revised Edition was published in 2020. The 2020 Guidelines includes 4 additional clinical questions (CQ), which brings the total to 99 CQ (12 on infectious disease, 29 on oncology and benign tumors, 29 on endocrinology and infertility and 29 on healthcare for women). Currently, a consensus has been reached on the Guidelines, and therefore, the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding Recommendation Level (A, B, C) is indicated.

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2017 edition.

Six years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the third revised edition was published in 2017. The 2017 Guidelines includes 10 additional clinical questions (CQ), which brings the total to 95 CQ (12 on infectious disease, 28 on oncology and benign tumors, 27 on endocrinology and infertility and 28 on healthcare for women). Currently a consensus has been reached on the Guidelines and therefore the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding recommendation level (A, B, C) is indicated.

Weight reduction using a formula diet recovers menstruation in obese patients with an ovulatory disorder.

Aim: To determine the effectiveness of a formula diet in weight reduction and the recovery of menstruation in obese patients with ovulatory disorders. Methods: After the enrollment of 39 obese women with ovulatory disorders, they replaced one or two of their three normal meals with a microdiet (MD) (240 kcal/meal) for 24 weeks. Physical, endocrinological, and biochemical tests were conducted before and at 12 and 24 weeks of the study. Of the 39 women enrolled, 26 were not taking clomiphene. They were divided into three groups according to their body weight outcomes and then analyzed for menstruation recovery. Results: A weight reduction of ≥5% was observed in 31 (81.5%) of the 39 women. There were significant decreases in the body weight and Body Mass Index during the study. Menstruation returned in 18 (69%) of the 26 patients without clomiphene treatment, with the recovery being significantly more prevalent in the groups (totally 81.0%) that exhibited a 5%-10% weight reduction and ≥10% weight reduction, compared to the group with a <5% weight reduction. Conclusion: The use of a formula diet effectively reduced the patients' body weight and led to the recovery of menstruation in these obese patients with ovulatory disorders.

Clinical Usefulness of Bakri Balloon Tamponade in the Treatment of Massive Postpartum Uterine Hemorrhage.

Intrauterine globe-shaped metreurynter tamponade has been used for some time to treat massive postpartum hemorrhage (PPH). More recently, the Bakri balloon has come into use to treat PPH. It is made of silicon, possesses a drainage lumen, and has a sausage-like spindle shape. The aim of the present study was to investigate the clinical usefulness of Bakri balloon tamponade for massive PPH. Subjects in the present study comprised 5 patients with uterine atony, 3 with placenta previa, and 2 with low-lying placenta. All patients exhibited massive PPH and resistance to conventional hemostatic managements. Bakri balloon tamponade was appliedto these 10 patients. The mean amounts of uterine bleeding (average ± SD) before and after Bakri insertion were2,732 ± 1,397 mL and 380 ± 376 mL, respectively. The median (third-first quartile ranges) volume of salineinflating the balloon was 200 mL (300-150 mL). The median (third-first quartile ranges) indwelling duration of Bakri balloon was 24 hours (24-11 hrs). The overall success rate of Bakri balloon tamponade was 90% (9/10).There were no cases of slipping out or complications regarding balloon placement. Our findings suggest that Bakri balloon tamponade may be applied to the treatment of massive PPH in uterine atony and placenta previa.The Bakri balloon appears to have the following merits: (1) easy insertion into the uterine cavity and low rate of slipping out, (2) proper conformability to the hemorrhagic area due to its spindle shape, (3) ability to monitor blood loss through the drainage lumen even after insertion.

Decreasing full-term neonatal birthweight over the past 2 decades in a single institute in Japan.

AIM: The aim of this study was to investigate whether full-term neonatal birthweight is decreasing or not. MATERIAL AND METHODS: Subjects were selected from the registration database of full-term singletons from a single local practitioner at two time-points, 1991 (n = 750) and 2011 (n = 442). Maternal age, parity, and smoking habits were recorded. Baseline characteristics included pre-pregnancy bodyweight (BW), body mass index (BMI), bodyweight before parturition, and weight gain during pregnancy. Neonatal birthweight and height were recorded. Variables correlated with neonatal size were investigated. RESULTS: Male birthweight decreased from 3248 ± 409 (n = 373) to 3149 ± 430 g (n = 230) (P < 0.001). Female birthweight also decreased from 3148 ± 378 (n = 377) to 3063 ± 343 g (n = 212) (P < 0.01). Gestational age was shorter (40.1 ± 1.1 to 39.6 ± 1.1 weeks, P < 0.001). Pre-pregnancy maternal BMI did not change (20.7 ± 2.6, n = 750 to 20.5 ± 2.7, n = 442). Weight gain during pregnancy decreased (11.3 ± 3.8 to 10.8 ± 3.4 kg, P < 0.05) and was positively correlated with birthweight (P < 0.001). On multiple regression analysis, time was inversely correlated with birthweight, while it was positively correlated with pre-pregnancy BMI, weight gain during pregnancy, and gestational age. CONCLUSIONS: In addition to maternal slenderness, increasing lower weight gain during pregnancy and medical intervention by physicians may in part contribute to the decrease in full-term birthweight over the past 2 decades.

Fourteen-year-old girl with recurrent luteal-phase-dependent episodes of high fever.

Recurrent episodes of high fever during the luteal phase are exceedingly rare. A 14-year-old girl with a 1-year history of recurrent febrile episodes associated with the menstrual cycle was referred to our department. Febrile episode (39-41°C) occurred for 10 to 12 days concomitantly with the luteal phase of each ovulatory cycle. To suppress the ovulatory cycle, gonadotropin releasing hormone agonist was administered for 5 months, and then febrile attack disappeared (34.5-36.2°C). Before and during gonadotropin releasing hormone agonist therapy, serum levels of inflammatory cytokines (interleukin [IL]-1ß, IL-2, IL-6, IL-8, IL-10, and tumor necrosis factor-α) were unchanged and all of these were within the normal ranges. In our case, luteal-phase-dependent febrile episodes may not be attributable to the intervention of inflammatory cytokines as major fever mediators.

Super-selective arterial embolization for uncontrolled bleeding in abdominal pregnancy.

BACKGROUND: Abdominal pregnancy with massive bleeding is life-threatening. Thus, multimodal treatment approaches are necessary. CASE: A 36-year-old woman with abdominal pregnancy at 14 weeks of gestation presented with abdominal pain due to intraabdominal bleeding. Laparotomy demonstrated massive bleeding from the placenta implanted in the right lower quadrant involving the posterior uterine wall, right adnexa, and small intestine. Because attempted removal of the placenta aggravated the bleeding, only the fetus was removed. To stop abdominal bleeding, embolization of the placental vasculature was successfully performed with a 2.0-F microcatheter after identification of the bleeding point with computed tomography arteriography. The patient was the treated with methotrexate. CONCLUSION: Super-selective arterial embolization with a microcatheter is a useful treatment of abdominal bleeding due to abdominal pregnancy.

Isolated adenomyotic cyst associated with severe dysmenorrhea.

A case of a 23-year-old, nulliparous female with a very rare isolated adenomyotic cyst inducing severe dysmenorrhea was seen. Transvaginal ultrasonographic tomography and magnetic resonance imaging (MRI) showed a 3 x 3-cm cystic mass within the left anterior wall of the uterine corpus. The cystic space was filled with hyperintense fluid on T1-weighted images, which was surrounded by hypointense tissue beside the right uterine corpus on T2-weighted images. The case was preliminarily diagnosed using MRI as having cavitated rudimentary uterine horn. However, hysterosalpingography excluded the possibility of uterine anomaly. A hemorrhagic adenomyotic cyst measuring 3 cm within the left anterior wall of the uterine corpus was surgically removed. There was no evidence of diffuse adenomyosis uteri. Dysmenorrhea completely disappeared postoperatively.

Torsion of the normal ovary and oviduct in a pre-pubertal girl.

We encountered a 10-year-old prepubertal girl with a normal ovary and oviduct torsion. Hemorrhagic infarction of the ovary and oviduct occurred, and these structures were laparoscopically removed. Torsion of the normal ovary and oviduct in a prepubertal girl is discussed.

Body fat patterning in polycystic ovary syndrome women as a predictor of the response to clomiphene.

BACKGROUND: To investigate the difference in the response to clomiphene citrate (CC) based on body fat distribution in women with polycystic ovary syndrome (PCOS). METHODS: Ninety anovulatory PCOS women were divided into two subgroups based on treatment response: women who ovulated with CC (CC responders, n = 49) and those who did not ovulate with CC (CC nonresponders, n = 41). Baseline characteristics included age, age at menarche, height, weight and body mass index [BMI; weight/(height)2]. Percentage of body fat, body fat mass and the ratio of trunk fat to leg fat mass amount (trunk-leg fat ratio) were measured by dual-energy X-ray absorptiometry (DEXA). RESULTS: Age, age at menarche and height did not differ between the two groups. However, trunk-leg fat ratio in CC responders (0.9 +/- 0.4) was significantly lower than that in CC nonresponders (1.3 +/- 0.4) (p < 0.001). Percentage of body fat, body fat mass and BMI were also lower in CC responders (p < 0.01). On multiple regression analysis, however, trunk-leg fat ratio proved to be a superior predictor of CC responder to percentage of body fat, BMI or body fat mass (standardized regression coefficient > or = 0.510; t-values > or = 3.432; p < 0.001). CONCLUSIONS: Response to CC in anovulatory PCOS women differs with body fat distribution.

Age-related change in the strength of correlation of lumbar spine bone mineral density with other regions.

OBJECTIVES: To investigate whether the strength of correlation of lumbar spine bone mineral density (BMD) with other regions differs with age. METHODS: Subjects were 336 premenopausal women aged 20-49 years and 218 postmenopausal women aged 50-69 years with right-side dominance. Age, height, weight, and years since menopause (YSM) were recorded. Subjects were classified into five subgroups at 10-year increments. BMD of the arms, lumbar spine (L2-4), pelvis, legs, and total body were measured by dual-energy X-ray absorptiometry (DEXA). RESULTS: Regional and total body BMD did not differ among women aged in their 20s, 30s, and 40s. However, in women aged over 50, regional and total body BMD gradually decreased with age. The strength of correlation of lumbar spine BMD with the left arm, right arm, left leg, right leg, and total body BMD gradually increased with advancing age (r=0.422-0.715, 0.376-0.714, 0.476-0.721, 0.491-0.734, and 0.642-0.800, respectively). However, the strength of correlation of lumbar spine BMD with pelvis BMD remained unchanged (r=0.512-0.622). CONCLUSIONS: Correlation of lumbar spine BMD with extremities BMD gradually strengthens with advancing age, while higher correlation of lumbar spine BMD with pelvis BMD remains unchanged. When lumbar spine BMD is predicted using values at sites such as forearm BMD, we should consider the patient's age.

Precedence of bone loss over changes in body composition and body fat distribution within a few years after menopause.

OBJECTIVE: The present study investigated the sequence of certain phenomena with a few years after menopause: bone mineral loss, decrease in lean body mass, increase in body fat mass, or the shift toward upper body fat distribution. METHODS: Subjects were 64 postmenopausal women aged 50-53 years with right side dominance (mean age+/-S.D., 51.4+/-1.1 years), and 59 age-matched regularly menstruating premenopausal women (51.7+/-1.2 years) serving as controls. Height, weight, body mass index (BMI, wt./ht.(2)), age at menopause (in postmenopausal women), and years since menopause (YSM) were recorded. Anthropometries, bone mineral density (BMD), and body fat distribution were assessed by dual-energy X-ray absorptiometry. RESULTS: Age at menopause and YSM in postmenopausal women were 51.7+/-1.2 and 2.3+/-1.7 years, respectively. Age, height, weight, BMI did not differ between the two groups. BMD of the bilateral arm, lumbar spine (L2-4), pelvis, and total body were significantly lower in postmenopausal women. However, leg BMD, trunk-leg fat ratio, body fat mass, and the lean body mass did not differ between the two groups. CONCLUSION: Within a few years after menopause, bone mineral loss precedes lean mass loss, increase in body fat mass, and a shift toward upper body fat distribution. We can say that bone tissue is more sensitive to hypogonadism than lean and fat tissues are.

Relationship of head lean mass to regional bone mineral density in elderly postmenopausal women.

OBJECTIVES: This study investigated the relationship of head lean mass to bone mineral density (BMD). METHOD: Subjects were 102 elderly women (> or =65-years-old) and 123 middle-aged postmenopausal women (<65-years-old) with right-side dominance. Age, height, weight, and years since menopause (YSM) were recorded. Lean mass of the head, arm, trunk, leg, and total body were measured by dual-energy X-ray absorptiometry (DEXA). BMD of the same regions were measured by DEXA. RESULTS: In elderly women, head lean mass was positively correlated with BMD of the head (r=0.389, P<0.01), left arm (r=0.235, P<0.05), right arm (r=0.280, P<0.05), lumbar spine (L2-4) (r=0.411, P<0.001), pelvis (r=0.490, P<0.001), left leg (r=0.572, P<0.001), right leg (r=0.558, P<0.001), and total body (r=0.529, P<0.001). These relationships remained significant after adjusting for age, height, and YSM. In addition, the strength of correlation of head lean mass with BMD was higher than those of other regional lean mass with respective BMD. In middle-aged women, strength of correlation of head lean mass with BMD was loose (r< or =0.238), while regional lean mass was more correlated with respective regional BMD. CONCLUSION: Factors related to lifestyle associated with higher (lower) head lean mass may contribute to higher (lower) BMD in elderly postmenopausal women.

Lean body mass and bone mineral density in physically exercising postmenopausal women.

OBJECTIVES: To investigate whether the relative contribution of body composition (lean and fat mass component) to postmenopausal bone mineral density (BMD) differs between women participating in physical exercise and sedentary women. METHODS: Subjects were 45 postmenopausal women participating in regular physical exercise and 89 sedentary controls aged 50-60 years. Baseline characteristics included age, height, weight, body mass index (BMI, Wt/Ht(2)), age at menopause, and years since menopause (YSM). Body fat mass, percentage of body fat, lean body mass, and lumbar spine BMD (L2-4) were measured by dual-energy X-ray absorptiometry. RESULTS: Although age, height, weight, BMI, and YSM did not differ between the two groups, lean body mass and lumbar spine BMD were significantly higher (P<0.05 and <0.001, respectively), while body fat mass and percentage of body fat mass were significantly lower in exercising women than in sedentary controls (P<0.05 and <0.05, respectively). In exercising women, BMD was positively correlated with lean body mass (r=0.415, P<0.01) but not with body fat mass (r=0.155, NS). Conversely, in sedentary controls, BMD was correlated with body fat mass (r=0.251, P<0.05) and lean body mass (r=0.228, P<0.05). CONCLUSIONS: Lean body mass is a more significant determinant of postmenopausal BMD in physically exercising women than in sedentary women.

Relationship of upper body fat distribution to higher regional lean mass and bone mineral density.

We investigated the relationship of upper body fat distribution to regional bone mineral density (BMD). Subjects were 361 regularly menstruating premenopausal women with right-side dominance. Age, height, and weight were recorded. Regional (arms, L2-L4 of the lumbar spine, and legs) BMD, regional (arms, trunk, and legs) lean mass, and the ratio of trunk fat mass to leg fat mass amount (trunk-leg fat ratio) were measured by dual-energy X-ray absorptiometry. Body fat distribution was assessed by trunk-leg fat ratio. Trunk-leg fat ratio was positively correlated with regional BMD ( r = 0.120-0.216; P < 0.05- P < 0.001) and regional lean mass ( r = 0.162-0.229; P < 0.01- P < 0.001). Regional lean mass was more positively correlated with regional BMD ( r = 0.319-0.475; P < 0.001). These relationships remained significant after adjusting for age and height. However, correlation of trunk-leg fat ratio with regional BMD disappeared after additionally adjusting for regional lean mass. In premenopausal women, upper body fat distribution is associated with higher regional BMD via greater regional lean mass irrespective of age and height.

Relative contribution of lean and fat mass component to bone mineral density in males.

We investigated the relative contribution of lean body mass (LBM) and body fat mass to bone mineral density (BMD) in 93 healthy Japanese male volunteers (mean age, 33.1 +/- 6.9 years; range, 18-54 years). Age, height (Ht), weight (Wt), and body mass index (BMI, Wt/Ht(2)) were recorded. Body fat mass, percentage of body fat, body fat mass/Ht(2), LBM, LBM/Wt, LBM/Ht(2), and lumbar spine (L2-L4) and total body BMD (TBBMD) were measured by dual-energy X-ray absorptiometry. On the Pearson correlation test, LBM was positively correlated with L2-L4 BMD. LBM, LBM/Wt, and LBM/Ht(2) were positively correlated with TBBMD. However, body fat mass and body fat mass/Ht(2) were not correlated with lumbar spine and total body BMD. On the partial correlation test, LBM was still correlated with lumbar spine ( r = 0.307, P < 0.05) and total body BMD ( r = 0.545, P< 0.0001), irrespective of age and height, whereas body fat mass was not correlated with BMD of these sites ( r = -0.069 and -0.169, respectively). We concluded that, in males, LBM is one of the significant determinants of BMD whereas body fat mass is a negligible BMD determinant.

Changes in endometrial wave-like movements in accordance with the phases of menstrual cycle.

OBJECTIVE: To investigate whether endometrial wave-like movements change with phases of the menstrual cycle. METHODS: Endometrial wave-like movements were observed by transvaginal sonographic tomography during 50 menstrual cycles of 20 regularly menstruating women. RESULTS: Endometrial wave-like movements were not observed during the early follicular phase. These movements proceeded perpendicularly to the longitudinal uterine axis and appeared at the midfollicular phase. In the periovulatory phase, waves reached a peak and moved from cervix to fundus. In the postovulatory phase, endometrial wave-like movements became parallel to the longitudinal uterine axis. In the midluteal phase, most of these waves disappeared. Immediately before menstruation, the waves reappeared moving from fundus to cervix. These movements continued until day 1 of the subsequent menstrual phase. CONCLUSION: Endometrial wave-like movements change with the passage of menstrual cycle. They appear to play an important role in the transport of sperm and cervical mucus and the excretion of menstrual flow.

Inverse relationship between the changes in trunk lean and fat mass during gonadotropin-releasing hormone agonist therapy.

OBJECTIVE: The aim of the present study was to investigate the relationship between the changes in lean and fat mass during gonadotropin-releasing hormone agonist (GnRH agonist) therapy. METHODS: Subjects were 24 premenopausal women (mean age, 39.5+/-9.4 years; range, 32-52 years) with uterine leiomyomas. They were given GnRH agonist (leuprorelin acetate, 3.75 mg) monthly for 4 months. Age and height were recorded. Body weight, regional and total body composition, and the ratio of trunk fat mass to leg fat mass (trunk-leg fat ratio) were assessed by whole body scanning with dual-energy X-ray absorptiometry. Changes in these variables were investigated. Relationships between the changes in regional lean and fat mass were investigated using Pearson's correlation test. RESULTS: Trunk fat mass significantly increased from 8616+/-3538 to 9265+/-3526 g (P<0.01) and trunk-leg fat ratio significantly increased (1.02+/-0.39 to 1.07+/-0.39, P<0.05). Trunk lean mass significantly decreased from 18,509+/-2602 to 17,916+/-2402 g (P<0.01). However, body weight, and lean and fat mass component in the extremities did not change. Change in trunk fat mass was inversely correlated with change in trunk lean mass (r=-0.439, P<0.05), but such relationships were not observed in arm and leg regions. CONCLUSION: Inverse relationship between the changes in trunk lean and fat mass is observed during GnRH agonist therapy.