Monophasic estrogen-progestogen therapy and sexuality in postmenopausal women.

OBJECTIVE: This study aimed to evaluate the effects of monophasic estrogen-progestogen therapy on the sexuality and climacteric symptoms of postmenopausal women. PATIENTS AND METHODS: A prospective, randomised, double-blind, crossover, placebo-controlled, single-centre study was carried out over a total of 12 consecutive months in 40 postmenopausal women with an intact uterus who had no contraindications to hormone therapy. Patients received 17beta-estradiol 2mg in combination with norethisterone acetate 1mg (Cliane) daily for 6 months or one placebo tablet daily for 6 months. The tablets were identical in appearance. After 6 months, the groups were crossed over and the patients were followed up for another 6 months. The groups were homogenous with respect to age, height, bodyweight, body mass index and race. For the statistical analysis, the group receiving hormone therapy was referred to as group A and the placebo group was designated group B, irrespective of the placebo/hormone therapy sequence. RESULTS: In group A there were fewer hot flashes (F=22.85, p<0.01) and an improvement in sexual interest (F=5.55, p<0.05). The sequence in which the medication was received resulted in a statistically significant difference with respect to dyspareunia (F=9.65, p<0.01) and satisfaction with the duration of penetration (F=6.58, p<0.05). In the intrapatient analysis of variation with respect to orgasmic capability and the presence of dialogue with partner regarding the couple's sexual life, whether the placebo was taken prior to or following hormone therapy was significant (F=17.12, p<0.001 and F=7.10, p<0.05, respectively). CONCLUSIONS: Monophasic estrogen-progestogen therapy has a beneficial effect on sexuality and on hot flashes in postmenopausal women.

The insulin-like growth factor-I system and hormone replacement therapy.

OBJECTIVE: To determine the effects of hormone replacement therapy on plasma concentrations of free and total insulin-like growth factor (IGF)-I, IGF binding protein (BP)-1, and IGFBP-3. DESIGN: Clinical study. SETTING: Gynecologic clinic at a university hospital. PATIENT(S): Seventy-one postmenopausal women. INTERVENTION(S): Six cycles of four different hormonal replacement therapy regimens: oral conjugated estrogens, transdermal estradiol, oral conjugated estrogens and norethisterone, and transdermal estradiol and norethisterone acetate. MAIN OUTCOME MEASURE(S): Blood samples were collected before and after treatment for measurement of free and total IGF-I, IGFBP-1, and IGFBP-3. RESULT(S): Conjugated estrogen replacement therapy is associated with a decrease in plasma concentration of total IGF-I and increase in concentrations of free IGF-I and IGFBP-1. Transdermal estrogens have no effect on total and free IGF-I and IGFBP-1 concentrations. Oral norethisterone plus conjugated estrogens increased free IGF-I and IGFBP-1 concentrations but did not change IGF-I concentrations. Transdermal conjugated estrogens plus norethisterone acetate increased free IGF-I concentrations but not total IGF-I or IGFBP-1 concentrations. The plasma concentration of IGFBP-3 did not change in any group. CONCLUSION(S): Alterations in total IGF-I concentration can occur depending on the route of hormone replacement therapy administration. Free IGF-I concentrations were elevated in all study groups except that treated with transdermal estrogens.

Inhibin B response to EFORT is associated with the outcome of oocyte retrieval in the subsequent in vitro fertilization cycle.

OBJECTIVE: To examine whether the magnitude of the rise in inhibin B levels after gonadotropin challenge is associated with subsequent response to ovarian stimulation during IVF. DESIGN: Inhibin B serum levels after EFORT (exogenous follicle-stimulating hormone ovarian reserve test). SETTING: Academic clinical practice. PATIENT(S): Serum samples from women who had undergone ovarian reserve screening with FSH in preparation for IVF. Thirteen of these women had a poor response in IVF (canceled cycle for low estradiol and/or no oocytes retrieved), and 19 had a good response (> or =10 oocytes retrieved). INTERVENTION(S): EFORT test. MAIN OUTCOME MEASURE(S): Baseline (day 3) serum E(2) (bE(2)), FSH (bFSH), and inhibin B (bInhB) levels and inhibin B and E(2) levels 24 hours after EFORT (DeltaInhB and DeltaE(2)). RESULT(S): The mean bInhB and DeltaInhB levels were significantly higher in good vs. poor responders. The odds ratio of having a good response for women with a DeltaInhB of 202 pg/mL was 51.8 times (95% CI = 6.1-1,244) the corresponding odds for women with a DeltaInhB of 49 pg/mL. As expected, DeltaE(2) was also significantly higher in good vs. poor responders; however, combination of DeltaE(2) plus DeltaInhB did not improve the odds for predicting IVF response. CONCLUSION(S): Our data suggest that DeltaInhB after EFORT may provide a method for predicting ovarian response to hyperstimulation in a subsequent IVF cycle.

Ureaplasma urealyticum colonization in the vaginal introitus and cervix of human immunodeficiency virus-infected women.

Ureaplasma urealyticum colonization was examined in paired cervical and introital specimens from 56 untreated HIV-seropositive women. Specimens were tested for U. urealyticum by polymerase chain reaction (PCR). Peripheral blood was examined for CD4 lymphocyte counts and HIV RNA concentration. U. urealyticum was detected in the cervix of 38 (69.1%) women. Introital U. urealyticum was present in 16 (28.6%) women, all of whom were cervical-positive. Cervical motion pain was present in 40.0% of women with U. urealyticum in the introitus and cervix, 23.8% of those with only cervical U. urealyticum and 5.9% of women negative for this organism (P=0.03). There was no relation between U. urealyticum colonization and CD4 lymphocyte count. However, 64.3% of women with introital U. urealyticum had circulating HIV RNA levels > 10,000 copies per ml as compared with 28.6% of women with only cervical U. urealyticum and 7.1% of women negative for this organism (P < 0.01).

A transverse thoracoabdominal skin flap for closure after radical mastectomy.

For closure of radical mastectomy defects, we present a new rotation flap using thoracoabdominal skin which crosses the midline of the trunk. This allows a rapid closure without the necessity of a delay.

Obstetric and gynecological care for Third World women.

The particular characteristics which women's health care in the Third World should have as compared with the situation in developed countries is discussed. Women in the Third World present a different prevalence of specific pathologies, give less attention to symptoms and to preventive measures, and the health system is usually not well adapted to respond to those characteristics. Examples of the difference between the needs of health care of Third World women compared to developed countries are taken from pre-natal care, prevention of cancer of the cervix and family planning. A critical analysis of the prevalent characteristics of present women's care in the Third World was done. Accordingly, some basic points to be considered in the implementation of women's health care for the Third World were proposed: avoid the uncritical replication of developed country's models to solve developing countries' health problems; application of a larger proportion of the resources to primary health care; a more aggressive attitude to increase preventive behavior, trying to maintain a continuous and not sporadic contact between the health system and the target population; great attention to reference and contra-reference to improve the integration of the various levels of the health system; delegation of functions from physicians to paramedical personnel; emphasis on health education, both formal and in the day-to-day contact between health agents and target population.

Endoscopic suspension of vaginal prolapse.

A new alternative for the surgical treatment of vaginal prolapse is presented in which the prolapse vagina is brought towards the abdominal wall using an extraperitoneal abdomino perineal approach with endoscopic control. The technique consists of a small suprapubic transverse incision to expose the abdominis rectus muscle aponeurosis. A Stamey needle is passed retropubically to the vagina and the extremity of a helicoidal suture previously made in the vaginal wall is introduced in the eye of the needle. It is then withdrawn to bring the thread to the suprapubic region. The maneuver is repeated on the other side and the threads are tied up over the aponeurosis of the rectus abdominis muscles, bringing the vagina to its original position. Endoscopic control is important to avoid bladder perforation.

Obstetric and gynecological care for Third World women.

The particular characteristics required for women's health care in the Third World are compared with these in developed countries. Women of the Third World present a different prevalence of specific diseases and give less attention to symptoms and to preventive measures. The health system is usually not well adapted to respond to these problems. Examples of the differences between the needs of health care of Third World women and those of developed countries are taken from certain aspects of pre-natal care, from the prevention of cancer of the cervix and from family planning. A critical analysis of the prevalent characteristics of women's care in the Third World was undertaken. As a result some basic points to be considered in the implementation of women's health care for the Third World were proposed: (1) avoid the uncritical simple replication of developed country's models; (2) application of a larger proportion of the resources to primary health care; (3) a more aggressive attitude to improve preventive measures; (4) efforts to maintain a continuous and non-sporadic contact between the health system and the target population: (5) greater attention to reference and contra-reference to improve the integration of the various levels of the health system; (6) delegation of functions from physicians to paramedical personnel; (7) emphasis on health education, both formal and in the day-to-day contact between health agents and target population.

IAMANEH and the new concept of reproductive health. International Association for Maternal and Neonatal Health.

Prof. Hubbert De Watteville, first Secretary General and founder of the International Federation of Gynecologists and Obstetricians (FIGO), created the International Association for Maternal and Neonatal Health (IAMANEH) in 1977, after realizing that the improvements in maternal and neonatal health observed in developed countries were not benefiting the so-called Third World. The purpose of IAMANEH was to stimulate local associations to take initiatives to improve the health of the women and their children. Lack of attention to women's own health has been characteristic of the emphasis on antenatal care to protect the newborn or family planning to reduce demographic growth, with little attention to the needs of women themselves. The evolution to the more comprehensive concepts of reproductive health has been slow and moved by a few visionaries in the Obstetrics and Gynecology establishment and by the women's rights movement. Currently, the concept has been accepted at world conferences, such as those of Cairo (1994) and Beijing (1995). Brazil officially incorporated an even wider concept of Comprehensive Women's Health Care, originated at the State University of Campinas and formally adopted by the Federal Government in 1984. It was placed in practice in the state of São Paulo between 1987 and 1990, showing important improvements in the quantity and quality of services provided to women.

Maternity care in developing countries: relevance of new technological advances.

It is suggested that improved maternity care in the developing world depends primarily on the increased provision of cost-effective, basic, easily accessible maternity care services. Expensive new technologies should be judged by their effectiveness, safety, technical feasibility, cost (including operating and maintenance expenses) and local need. After identifying the major causes of morbidity and mortality, priority should be given to interventions applicable at the local level and which do not require highly or specially trained educated personnel.

PIP: Improved maternity care in the developing world depends primarily on the increased provision of cost-effective, basic, easily accessible maternity care services. Expensive new technologies should be judged by their effectiveness, safety, technical feasibility, cost (including operating and maintenance expenses) and local need. After identifying the major causes of morbidity and mortality, priority should be given to interventions applicable at the local level and which do not require highly or specially trained educated personnel. Given the lack of access to any prenatal and intrapartum care for a majority of women in many settings, it should be clear that expenditures on costly monitoring and ultrasonographic equipment are an unacceptable investment until a majority of women have access to basic prenatal and intrapartum care. Simpler clinical diagnostic tools, which can be applied at the primary health care level, together with provision of prenatal and delivery, nutrition, immunization and fertility regulation services are the most relevant technologies for maternity care for the present health situation in most LDCs. Complicated technologies should be limited to a few tertiary level centers within a well-structured tiered health care system. A recent meeting of the International Federation of Gynecologists and Obstetricians (FIGO), unfortunately revealed the popularity of special high technology displays and sessions and lack of interest in the essential issue of rural health care accessibility. An example of an appropriate technology is the foam test described by Clements detecting fetal lung maturation; inappropriate technology, for LDCs includes electronic fetal monitoring (EFM). Even in the US, EFM as a routine part of labor care has been controversial. It is certainly inappropriate where 40-90% of women deliver at home without professional assistance. The cost of EFM for 289 women in Brazil during a 13-month period would have paid for 5.5 prenatal clinics at the basic health level for 1 year which could provide 13,200 visits of assistance to 1886 women and would have averted 8 times more perinatal deaths.

Preliminary experiment with computerized anamnesis in gynecology and reproductive health.

The Hospital of the Faculty of Medical Sciences of the State University of Campinas is implementing an Integrated Health Care Programme, whose objectives are early detection of risk factors of several diseases and the evaluation of the patient's reproductive health at the moment of the first visit to the Hospital. The initial results of this program encouraged us to try to apply it all to our own clientele. The present lack of material resources and qualified manpower leads us to concentrate all our attention on the patient's immediate complaints. This situation indicated to us that the only way to implement the program should be by means of a computerized questionnaire able to detect diseases and risk factors early. This paper presents the preliminary results of the application of computerized questionnaires to evaluate health risks. The authors conclude: The application of a computerized questionnaire met with very favorable reception by the clientele; In some segments of the population, the questionnaire can be answered by the patients in direct interaction with the computer; Programmes which evaluate risk factors need to be carefully revised before being put to use; The system operates on a relatively low cost basis, which could bring undeniable benefits to primary health care.

PIP: This paper reports the preliminary results of the experimental use of a computerized questionnaire aimed at assessing health risks in women attending an integrated health care program. The questionnaire, which includes over 140 items, seeks to calculate reproductive risk as well as the risk of cancers of the cervix, breast, endometrium, ovary, stomach, and lung. It has been tested, either on a self-administered basis or with the aid of nursing personnel, on 500 patients at a hospital clinic. It took subjects 10-34 minutes to complete the questionnaire, with a median time of 18 minutes. 90% of respondents reported that they enjoyed answering the questions and had no difficulties understanding the text. When questionnaire results were compared with the results of clinical evaluations carried out by family planning clinic staff, it was found that 346 patients were using some type of contraceptive method that had not been revealed to clinic personnel; moreover, according to the questionnaire, 27% of the women who were using oral contraceptives had clinical conditions that contraindicated use of this method. These women showed overwhelming acceptance of the computer's recommendation that pill use be discontinued on the basis of health hazards. This program can be processed in small, cost-effective national microcomputers, facilitating its gradual installation in the primary health care network. It could become a useful tool in the reference and counterreference process between the primary health care system and centers of secondary and tertiary health care.

Uterine artery embolization for the treatment of uterine leiomyomata.

OBJECTIVES: To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids. METHODS: Twenty-six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow-up was performed before the procedure, at 3 months, and 1 year after. RESULTS: All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm(3), after 3 months 255 cm(3) and after 1 year 202 cm(3). The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow-up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients). CONCLUSIONS: UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Integrated approach to women's health.

The objective of this study was to demonstrate the importance of the practical application of the concept of reproductive health in São Paulo, Brazil, from 1991 to 1998 at the Pérola Byington Hospital with a new model of Primary Health Care (PHC) in which 2000 women/day, separated into two groups and over 45 years, was attended by nurses trained to detect the most frequently occurring gynecological problems supervised by doctors, who finalized the visit of each patient. The results demonstrated the advantages and viability of this strategy and also the bad health conditions of the women. Based on the high incidence of different kind of diseases detected, programs were set up for the diagnosis and treatment of gynecological cancer, STD, AIDS, hypertension, diabetes, etc. The results of two of these control programs, cervical cancer and breast cancer, demonstrated a significant increase in the diagnosis of early lesions. An economic study demonstrated an obvious and significant impact of this model not only in saving lives, but also in decreasing financial expenses in health.

Endometriosis in the presacral nerve.

OBJECTIVE: The authors report a case of extremely aggressive endometriosis involving a 32-year-old woman. METHODS: Different types of medication were used and various surgical procedures applied in order to reduce the clinical signs and symptoms. Among the surgical procedures employed was presacral neurectomy when endometriosis was identified in the presacral nerve. RESULTS: Receptor determination in the surgical piece was negative. CONCLUSIONS: The etiopathogenic and therapeutic aspects of this process are discussed.

The effects of systemic hormonal replacement therapy on the skin of postmenopausal women.

OBJECTIVE: The aim of this study was to determine the effects of hormonal replacement therapy on the skin of postmenopausal women. METHOD: Forty-one postmenopausal women were randomly allocated to receive either hormonal replacement (valerate estradiol--2 mg/day for 21 days and cyproterone acetate--1 mg/day for 10 days) or placebo, both in a cyclic scheme for 6 months. Neither patients nor investigators were aware of the group allocation. Histologic changes were evaluated by skin biopsy of the left upper arm at baseline and after 6 months of treatment, utilizing computerized image analysis to assess the ratio area of epidermis/basement membrane length (AE/BML), ratio area of keratin/basement membrane length (AK/BML) and collagen and elastic fibers content. RESULT: Collagen content of the left upper arm increased after 6 months of treatment only in the hormonal group (+6.49%; P < 0.05). Other parameters did not present any significant alteration after treatment in both groups. CONCLUSION: Hormonal replacement for climacterics increases skin collagen content.

Menstrual pattern and ovarian function in women with hyperprolactinemia.

Prolactin (PRL) and progesterone were systematically measured in all women presenting with amenorrhea, oligomenorrhea or galactorrhea at the Infertility Clinic of the Department of Obstetrics and Gynecology, State University of Campinas, Brazil, during a period of 34 months. The same hormonal assays were done to all infertile patients presenting for the first time during the last 6 months of the same period, for a total of 190 subjects. Fifty-five patients with amenorrhea, 38 with oligomenorrhea and 97 with normal cycles, 20 of whom had galactorrhea, were included in the study. Fifty-five percent of amenorrheic patients, 37% of oligomenorrheic and 9% of those with normal menses had elevated PRL. The mean PRL was higher the greater the menstrual disturbance but was not influenced by presence or absence of galactorrhea. Short luteal phase was the ovarian function condition most frequently associated with high PRL among women with normal menses.

Evolution of cystic and adnexal tumors identified by echography.

The authors present their experience in detecting volume and echostructure alterations of the ovary in 14,525 women examined echographically and clinically. They analyzed 499 adnexal tumors and observed after clinical follow-up and echography that 60.6% of the cystic-septa tumors had involuted spontaneously. Percentage of spontaneous resolution was higher in small-diameter tumors, avoiding unnecessary surgery.

A double-blind trial of four medications to treat severe premenstrual syndrome.

OBJECTIVE: To determine the efficacy of fluoxetine (10 mg), alprazolam, propanolol and pyridoxine in the treatment of severe premenstrual syndrome (PMS). METHOD: One-hundred and twenty women were divided into four groups of 30 patients. Patients were submitted to a randomized, double-blind, placebo-controlled treatment and were given 3 months of placebo and 3 months of active drug. The active drug was pyridoxine (300 mg/day) in group 1; alprazolam (0.75 mg/day) in group 2; fluoxetine (10 mg/day) in group 3; and propanolol (20 mg/day and 40 mg during the menstrual period) in group 4. RESULTS: Fluoxetine in 10-mg doses obtained a mean reduction of 65.4% in symptoms, followed by propanolol (58.7%), alprazolam (55.6%), pyridoxine (45.3%) and placebo (39.4-46.1%). CONCLUSION: Fluoxetine in 10-mg doses presented the best results for treating premenstrual syndrome.

Histological classification of endometriosis as a predictor of response to treatment.

OBJECTIVES: To evaluate the usefulness of the histological classification of endometriosis in predicting responses to treatment. METHODS: We evaluated 412 biopsy specimens from 241 patients with pelvic endometriosis. Pain and infertility were evaluated before surgery. Disease location and stage of development were analyzed according to the 1985 American Society of Reproductive Medicine (ASRM) classification. Histological findings were classified as stromal, well-differentiated, undifferentiated, and mixed endometriosis. Clinical response to pain or infertility was evaluated. RESULTS: Histological findings, disease location and stage of development, and response to treatment were compared. Undifferentiated endometriosis was more frequently associated with stages III/IV than the well-differentiated and stromal histological types. Pure or mixed undifferentiated patterns were more frequently associated with rectovaginal endometriosis. When considering pain symptoms, patients presenting well-differentiated or stromal histological patterns responded better to therapeutic treatment than those who presented undifferentiated histological patterns. There were no significant differences in cases related to sterility. CONCLUSIONS: The histological categorization of endometriosis can help predict the behavioral patterns of the disease.

A randomized study of total abdominal, vaginal and laparoscopic hysterectomy.

OBJECTIVES: To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy. METHODS: Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin-6 dosages) were compared by using Kruskal-Wallis, Dunn non-parametric test and variance analysis with repeated measurements. RESULTS: Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin-6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy. CONCLUSIONS: Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.