Ulipristal acetate versus levonorgestrel-releasing intrauterine system for heavy menstrual bleeding (UCON): a randomised controlled phase III trial.

Background: Heavy menstrual bleeding affects one in four women and negatively impacts quality of life. Ulipristal acetate is prescribed to treat symptoms associated with uterine fibroids. We compared the effectiveness of ulipristal acetate and the levonorgestrel-releasing intrauterine system at reducing the burden of heavy menstrual bleeding, irrespective of the presence of fibroids. Methods: This randomised, open-label, parallel group phase III trial enrolled women over 18 years with heavy menstrual bleeding from 10 UK hospitals. Participants were centrally randomised, in a 1:1 ratio, to either three, 12-week treatment cycles of 5 mg ulipristal acetate daily, separated by 4-week treatment-free intervals, or a levonorgestrel-releasing intrauterine system. The primary outcome, analysed by intention-to-treat, was quality of life measured by the Menorrhagia Multi-Attribute Scale at 12 months. Secondary outcomes included menstrual bleeding and liver function. The trial is registered with ISRCTN, 20426843. Findings: Between June 5th, 2015 and February 26th, 2020, 236 women were randomised, either side of a recruitment suspension due to concerns of ulipristal acetate hepatoxicity. Subsequent withdrawal of ulipristal acetate led to early cessation of recruitment but the trial continued in follow-up. The primary outcome substantially improved in both groups, and was 89, (interquartile range [IQR] 65 to 100, n = 53) and 94, (IQR 70 to 100, n = 50; adjusted odds ratio 0.55, 95% confidence interval [CI] 0.26-1.17; p = 0.12) in the ulipristal and levonorgestrel-releasing intrauterine system groups. Rates of amenorrhoea at 12 months were higher in those allocated ulipristal acetate compared to levonorgestrel-releasing intrauterine system (64% versus 25%, adjusted odds ratio 7.12, 95% CI 2.29-22.2). Other outcomes were similar between the two groups and there were no cases of endometrial malignancy or hepatotoxicity due to ulipristal acetate use. Interpretation: Our findings suggested that both treatments improved quality of life. Ulipristal was more effective at inducing amenorrhoea. Ulipristal has been demonstrated to be an effective medical therapeutic option but currently its use has restrictions and requires liver function monitoring. Funding: UK Medical Research Council and National Institute of Health Research EME Programme (12/206/52).

Extinct in the wild: The precarious state of Earth's most threatened group of species.

Extinct in the Wild (EW) species are placed at the highest risk of extinction under the International Union for Conservation of Nature Red List, but the extent and variation in this risk have never been evaluated. Harnessing global databases of ex situ animal and plant holdings, we report on the perilous state of EW species. Most EW animal species-already compromised by their small number of founders-are maintained at population sizes far below the thresholds necessary to ensure demographic security. Most EW plant species depend on live propagation by a small number of botanic gardens, with a minority secured at seed bank institutions. Both extinctions and recoveries are possible fates for EW species. We urgently call for international effort to enable the latter.

Conscious sedation for office hysteroscopy: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the role of conscious sedation on pain control in office hysteroscopy. METHODS: MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to the 30th October 2020 in order to perform a systematic review and meta-analysis of all randomized controlled trials investigating women undergoing office hysteroscopic procedures, allocated to either conscious sedation or a suitable comparator, where the outcome was pain. Data regarding adverse events, feasibility and satisfaction/acceptability were also collected. The Risk of Bias 2 tool was used to assess study quality. Standard mean differences (SMD) or Odds Ratios (OR), and their 95% confidence intervals (CIs) were calculated for continuous (e.g. mean pain) and dichotomous (e.g. side-effects) outcomes, respectively. RESULTS: The literature search returned 339 results, of which seven studies were included for systematic review, with five studies having data suitable for meta-analysis. Intravenous conscious sedation, when compared with local anesthesia, reduced pain during (SMD -0.26, 95% CI -0.51 to -0.01), but not after (SMD -0.18, 95% CI -0.43 to 0.07) office hysteroscopy. No significant difference in side-effects were noted (OR 15.58, 95% CI 0.08 to 2891.91). Intravenous conscious sedation, when compared to an oral analgesic and antispasmodic, was associated with increased pain, both during (SMD 1.03, 95% CI 0.56 to 1.49) and after (SMD 0.49, 95% CI 0.04 to 0.93) hysteroscopy and had significantly more side-effects (OR 134.33, 95% CI 16.14 to 1118.17). Inhalational conscious sedation (70% N2O/30% O2), when compared to oral analgesia and anxiolysis, showed the greatest reduction in pain during hysteroscopy (SMD -1.04, 95% CI -1.57 to -0.52), however side-effects were not reported. Whilst patients and hysteroscopists were more satisfied with deeper levels of sedation, resulting side-effects, such as delirium, increased the level of post-procedural attention required, leading to a significantly lower level of satisfaction amongst nursing staff. CONCLUSION: The routine use of conscious sedation in contemporary hysteroscopic practice should be avoided in the absence of any clear reduction in pain and a higher risk of side-effects.

Pain and Operative Technologies Used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials.

OBJECTIVE: To identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures. DATA SOURCES: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords "hysteroscop*," "endometrial ablation," "outpatient," "ambulatory," "office," and associated Medical Subject Headings. METHODS OF STUDY SELECTION: Randomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction. TABULATION, INTEGRATION, AND RESULTS: The search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited. CONCLUSION: Pain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.

A Systematic Review of the Effect of Type, Pressure, and Temperature of the Distension Medium on Pain During Office Hysteroscopy.

OBJECTIVE: To identify the optimal distension medium type, pressure, and temperature to minimize pain during office hysteroscopy. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to January 29, 2020. METHODS OF STUDY SELECTION: We included randomized controlled trials in which women undergoing office hysteroscopy were randomized to either a distension medium type, pressure, or temperature against a suitable control, where pain was an outcome. Data regarding feasibility, visualization, complications, and satisfaction were also collected. TABULATION, INTEGRATION, AND RESULTS: The literature search returned 847 studies, of which 18 were included for systematic review and 17 for meta-analysis. There was no significant difference in intraprocedural pain when comparing the use of normal saline against carbon dioxide (standardized mean difference [SMD], -0.12; 95% confidence interval [CI], -0.36 to 0.13). Subgroup analysis of high-quality studies revealed a statistically significant reduction in postprocedural pain with normal saline (SMD, -0.65; 95% CI, -1.14 to -0.16). Side effects were less frequent (Peto odds ratio, 0.29; 95% CI, 0.20-0.40) and patient satisfaction was higher (SMD, 1.39; 95% CI, 0.51-2.28) with normal saline compared with carbon dioxide. Pressures of ≤40 mm Hg reduced intraprocedural pain (SMD, -0.67; 95% CI, -1.09 to -0.26) at the expense of a higher proportion of unsatisfactory views (81%-89% at ≤40 mm Hg vs 95%-99% at ≥50 mm Hg). Postprocedural pain was reduced with lower filling pressures. Warming saline did not reduce intraprocedural pain (SMD, 0.59; 95% CI, -0.14 to 1.33). CONCLUSION: Normal saline, instilled at the lowest pressure to acquire a satisfactory view, should be used for uterine distension during office hysteroscopy to minimize pain.

Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis.

OBJECTIVE: To investigate the effect of the vaginoscopic approach to office hysteroscopy on patients' experience of pain, when compared with the traditional approach where a vaginal speculum is used. METHODS: Medline, Embase, CINAHL and the Cochrane library were searched from inception until December 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating vaginoscopy compared to traditional hysteroscopy on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting. Data regarding procedural time, feasibility, incidence of vasovagal reactions and complications, acceptability and satisfaction were also recorded. RESULTS: The literature search returned 363 results of which seven were selected for systematic review, and six for meta-analysis. The vaginoscopic approach was associated with a statistically significant reduction in pain (4 studies including 2214 patients; SMD -0.27, 95 % CI -0.48 to -0.06), procedural time (6 studies including 2443 patients; SMD -0.25, 95 % CI -0.43 to -0.08) and the incidence of vasovagal episodes (3 studies including 2127 patients; OR 0.35; 95 % CI 0.15 to 0.82). Failure rates between the two techniques were similar (p = .90). No study reported significant differences in complications or patient or clinician acceptability or satisfaction. CONCLUSION: Clinicians performing office hysteroscopy should use the vaginoscopic technique because it makes office hysteroscopy quicker, less painful and reduces the likelihood of inducing a vasovagal reaction. The traditional approach should only be used when vaginoscopy fails or when the need for cervical dilatation is anticipated.

Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis.

OBJECTIVE: To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy. METHODS: Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected. RESULTS: The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis. CONCLUSION: Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation.

The Prevalence of Thyroid Dysfunction and Autoimmunity in Women With History of Miscarriage or Subfertility.

OBJECTIVE: To describe the prevalence of and factors associated with different thyroid dysfunction phenotypes in women who are asymptomatic preconception. DESIGN: Observational cohort study. SETTING: A total of 49 hospitals across the United Kingdom between 2011 and 2016. PARTICIPANTS: Women aged 16 to 41years with history of miscarriage or subfertility trying for a pregnancy. METHODS: Prevalences and 95% confidence intervals (CIs) were estimated using the binomial exact method. Multivariate logistic regression analyses were conducted to identify risk factors for thyroid disease. INTERVENTION: None. MAIN OUTCOME MEASURE: Rates of thyroid dysfunction. RESULTS: Thyroid function and thyroid peroxidase antibody (TPOAb) data were available for 19213 and 19237 women, respectively. The prevalence of abnormal thyroid function was 4.8% (95% CI, 4.5-5.1); euthyroidism was defined as levels of thyroid-stimulating hormone (TSH) of 0.44 to 4.50 mIU/L and free thyroxine (fT4) of 10 to 21 pmol/L. Overt hypothyroidism (TSH > 4.50 mIU/L, fT4 < 10 pmol/L) was present in 0.2% of women (95% CI, 0.1-0.3) and overt hyperthyroidism (TSH < 0.44 mIU/L, fT4 > 21 pmol/L) was present in 0.3% (95% CI, 0.2-0.3). The prevalence of subclinical hypothyroidism (SCH) using an upper TSH concentration of 4.50 mIU/L was 2.4% (95% CI, 2.1-2.6). Lowering the upper TSH to 2.50 mIU/L resulted in higher rates of SCH, 19.9% (95% CI, 19.3-20.5). Multiple regression analyses showed increased odds of SCH (TSH > 4.50 mIU/L) with body mass index (BMI) ≥ 35.0 kg/m2 (adjusted odds ratio [aOR] 1.71; 95% CI, 1.13-2.57; P = 0.01) and Asian ethnicity (aOR 1.76; 95% CI, 1.31-2.37; P < 0.001), and increased odds of SCH (TSH ≥ 2.50 mIU/L) with subfertility (aOR 1.16; 95% CI, 1.04-1.29; P = 0.008). TPOAb positivity was prevalent in 9.5% of women (95% CI, 9.1-9.9). CONCLUSIONS: The prevalence of undiagnosed overt thyroid disease is low. SCH and TPOAb are common, particularly in women with higher BMI or of Asian ethnicity. A TSH cutoff of 2.50 mIU/L to define SCH results in a significant proportion of women potentially requiring levothyroxine treatment.

Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis.

OBJECTIVE: To identify the most effective analgesia for women undergoing office hysteroscopy. DATA SOURCES: We searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library from inception until August 2019 for studies that investigated the effect of different analgesics on pain control in office hysteroscopy. METHODS OF STUDY SELECTION: We included randomized controlled trials that investigated the effect of analgesics on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting compared with the control group. TABULATION, INTEGRATION, AND RESULTS: The literature search returned 561 records. Twenty-two studies were selected for a systematic review, of which 16 were suitable for meta-analysis. There was a statistically significant reduction in pain during office hysteroscopy associated with preprocedural administration of nonsteroidal anti-inflammatory drugs (NSAIDs) (standardized mean difference [SMD] -0.72; 95% confidence interval [CI] -1.27 to -0.16), opioids (SMD -0.50; 95% CI -0.97 to -0.03), and antispasmodics (SMD -1.48; 95% CI -1.82 to -1.13), as well as with the use of transcutaneous electrical nerve stimulation (TENS) (SMD -0.99; 95% CI -1.67 to -0.31), compared with the control group. Moreover, similar reduction in pain was observed after office hysteroscopy: NSAIDs (SMD -0.55; 95% CI -0.97 to -0.13), opioids (SMD -0.73; 95% CI -1.07 to -0.39), antispasmodics (SMD -1.02; 95% CI -1.34 to -0.69), and TENS (SMD -0.54; 95% CI -0.95 to -0.12). Significantly reduced pain scores with oral NSAID administration during (SMD -0.87; 95% CI -1.59 to -0.15) and after (SMD -0.56; 95% CI -1.02 to -0.10) office hysteroscopy were seen in contrast to other routes. Significantly more adverse effects were reported with the use of opioids (p <.001) and antispasmodics (p <.001) when compared with the control group, in contrast to NSAIDs (p = .97) and TENS (p = .63). CONCLUSION: Women without contraindications should be advised to take oral NSAIDs before undergoing office hysteroscopy to reduce pain during and after the procedure. TENS should be considered as an alternative analgesic in women with contraindications to NSAIDs.

The effectiveness of gynaecological teaching associates in teaching pelvic examination: a systematic review and meta-analysis.

CONTEXT: An increasing number of graduating students are unable to competently and confidently perform a pelvic examination. Gynaecology teaching associates (GTAs) teach technical and communication skills and offer immediate feedback. The objective was to perform a systematic literature review to assess whether teaching pelvic examinations using real women who are trained to give instructions on technique and feedback improves the competence, confidence and communication skills of trainees when compared with traditional teaching methods. METHODS: MEDLINE, EMBASE, the Cochrane Library, CINAHL and the ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were randomised clinical trials (RCTs) and controlled studies that investigated the use of GTAs to teach students or health-related professionals the pelvic examination. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes measured were: self-reported confidence, assessed competence and assessed communication skills. The standard mean difference (SMD) was derived for each study where possible and heterogeneity across studies was quantified using the I(2) statistic. In the presence of substantial variation, the data were pooled using a random effects model. RESULTS: Eleven studies with 856 participants were included: five RCTs and six observational studies. GTA training improved competence compared with other teaching methods and the finding of enhanced competence was consistent when the pooled analysis was restricted to RCTs. Communication skills were also improved with GTA teaching, but to a lesser degree, whereas no effect on student confidence was observed. Statistical heterogeneity was present for all outcomes when data were pooled. CONCLUSION: Our findings suggest that GTA-based teaching of pelvic examination is associated with improvement in the competence and communication skills of trainees. However, further larger-scale studies with standardised relevant educational outcomes are needed to confirm these findings.

Investigating the effect of ethnicity on IVF outcome.

Success rates for IVF among women from different ethnic groups have been inconclusive. In this study, the relationship between ethnicity and IVF outcome was investigated. Results of a cohort study analysing 13,473 first cycles were compared with the results of meta-analysed data from 16 published studies. Adjustment was made for age, body-mass index, cause of infertility, duration of infertility, previous live birth, previous spontaneous abortion and number of embryos transferred. Black and South Asian women were found to have lower live birth rates compared with White women: Black versus White (OR 0.42 [0.25 to 0.70]; P = 0.001); South Asian versus White (OR 0.80 [0.65t o 0.99]; P = 0.04). Black women had significantly lower clinical pregnancy rates compared with White women (OR 0.41 [0.25 to 9 0.67]; P < 0.001). The meta-analysed results also showed that Black and South Asian women had statistically significant reduced odds of live birth (OR 0.62 [0.55 to 0.71); P < 0.001 and OR 0.66 [0.52 to 0.85); P = 0.001, respectively). Black and South Asian women seem to have the poorest outcome, which is not explained by the commonly known confounders. Future research needs to investigate the possible explanations for this difference and improve IVF outcome for all women.

Bipolar radiofrequency compared with thermal balloon ablation in the office: a randomized controlled trial.

OBJECTIVE: To estimate the effectiveness of office-based bipolar radiofrequency ablation compared with thermal balloon ablation of the endometrium for the treatment of heavy menstrual bleeding at 5-year follow-up. METHODS: A single blind randomized controlled trial was conducted in an office hysteroscopy clinic in a university teaching hospital. A total of 81 women were randomly allocated to either bipolar radiofrequency ablation or thermal balloon ablation in an office setting avoiding use of general anesthesia or conscious sedation. The primary outcome for the trial was amenorrhea at 6 months follow-up. In this planned secondary analysis, the main outcome measures were amenorrhea rates, patient satisfaction, health-related quality of life, and incidence of further uterine surgery at 5-year follow-up. RESULTS: At 5-year follow-up, 59 (73%) women responded to postal questionnaires. Amenorrhea was reported in 60% of thermal balloon ablation and 62% of bipolar radiofrequency ablation (odds ratio [OR] 1.09 [0.38-3.11]) and satisfaction with treatment outcome in 96% of thermal balloon ablation and 96% of bipolar radiofrequency ablation (OR 0.92 [0.05-25.59]). Further surgical intervention was needed in three of 29 (10%) women treated with bipolar radiofrequency ablation compared with four of 30 (13%) of women treated with thermal balloon ablation (P=.7). There was no significant difference in either condition-specific or generic health-related quality-of-life measures. CONCLUSION: There was no difference in the effectiveness of bipolar radiofrequency ablation and thermal balloon ablation performed in an office setting at 5-year follow-up. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01124357. LEVEL OF EVIDENCE: I.

Hysteroscopic morcellation compared with electrical resection of endometrial polyps: a randomized controlled trial.

OBJECTIVE: To evaluate whether hysteroscopic morcellation or bipolar electrosurgical resection is more favorable for removing endometrial polyps in an office setting in terms of feasibility, speed, pain, and acceptability. METHODS: A multicenter, single-blind, randomized, controlled trial of office hysteroscopic morcellation compared with electrosurgical resection was conducted. A total of 121 women were randomly allocated to polyp removal by one of the two methods in an office setting. The outcomes assessed were time taken to complete the endometrial polypectomy, defined as the time from insertion to removal of vaginal instrumentation, completeness of polyp removal, acceptability, and pain measured on a 100-mm visual analog scale. RESULTS: The median time taken to complete the procedure was 5 minutes and 28 seconds for morcellation compared with 10 minutes and 12 seconds for electrosurgical resection (P<.001). The polyps were completely removed in 61 out of 62 (98%) women assigned to morcellation compared with 49 out of 59 (83%) women treated with electrosurgical resection (odds ratio 12.5; 95% confidence interval [CI] 1.5-100.6; P=.02). The mean pain scores during the procedure favored morcellation by 16.1 points on average (35.9 compared with 52.0; 95% CI for difference, -24.7 to -7.6; P<.001). Overall, 99% of women found office polypectomy to be acceptable, with only one woman in the electrosurgical resection group considering the procedure unacceptable. CONCLUSION: In comparison to electrosurgical resection during hysteroscopic polypectomy, morcellation was significantly quicker, less painful, more acceptable to women, and more likely to completely remove endometrial polyps compared with electrosurgical resection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01509313.

Recurrent postmenopausal bleeding: a prospective cohort study.

STUDY OBJECTIVE: To estimate the prevalence of genital tract diseases in women with initial and recurrent postmenopausal bleeding (PMB) to help inform diagnostic pathways. DESIGN: Prospective cohort study (Canadian Task Force classification: II-2). SETTING: Large urban teaching hospital. PATIENTS: Of 1938 consecutive women with postmenopausal bleeding, 106 (5%) were investigated for a recurrent episode after having normal findings of previous investigations. INTERVENTIONS: All women underwent pelvic examination and ultrasound scanning. An endometrial biopsy was performed when endometrial thickness was >4 mm in women with a first episode of PMB, with recourse to outpatient hysteroscopy after correlation between clinical and pathologic findings. All women with a recurrent PMB episode underwent endometrial biopsy and outpatient hysteroscopy. MEASUREMENTS AND MAIN RESULTS: The risk of having endometrial cancer or hyperplasia with atypia was significantly less in women with recurrent PMB (9%) as compared with those with a first episode of PMB (8%) (p = .002), but were significantly more likely to have benign endometrial polyps (28%) compared with women with a first episode of PMB (19%) (relative risk, 1.47; 95% confidence interval, 1.07-2.02; p = .02). CONCLUSION: Recurrent PMB results in less likelihood of premalignant and malignant endometrial disease; however, in 1 of 4 women PMB is caused by endometrial polyps. First-line investigation in women with recurrent PMB should be tests that have high accuracy for enabling diagnosis of focal diseases, such as outpatient hysteroscopy or saline infusion sonography.

Systemic lupus erythematosus: clinical presentations.

Systemic lupus erythematosus is a complex multisystem autoimmune disease that affects 1 in 2000 adult women in the United Kingdom. Lupus affects Afrocaribbeans and South Asians more frequently and more severely than white British. The disease can affect almost any part of the body and is characterised by remission and relapses. It is most common in women of reproductive age but can present at any age from 1 to 90 years and in men, but the diagnosis is probably missed in some men. It is important to distinguish active lupus features due to inflammatory and thrombotic mechanisms from chronic damage and to be aware that infection is an important trigger that may co-exist or mimic lupus activity. The disease is associated with a variety of autoantibodies that can help in making the diagnosis. Monitoring the disease is usually done using a clinical disease activity index such as the BILAG index, anti-dsDNA antibodies, C3 and C4 levels. Anti-C1q antibodies may have a role in monitoring the disease and in predicting those at risk of renal involvement or flare. The prognosis depends on the organs involved. There is an increased risk of premature atherosclerosis as a complication of lupus and this and infection are the most common causes of death in lupus patients.