Effect of Radiofrequency Endometrial Ablation on Dysmenorrhea.

STUDY OBJECTIVE: To examine rates of dysmenorrhea after radiofrequency endometrial ablation in patients with and without known dysmenorrhea symptoms prior to the procedure in a diverse population. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Academic gynecology practice. PATIENTS: A total of 307 women underwent endometrial ablation between 2007 and 2013 at our institution. Patients who had preoperative and postoperative pain symptom assessments as well as a description of pain timing recorded were included in our analysis. Exclusion criteria were age <19 years and operative biopsy findings consistent with complex atypical hyperplasia. INTERVENTIONS: The difference in preoperative and postoperative rates of dysmenorrhea was evaluated. Demographic information and other outcome variables were used to evaluate factors associated with resolution of dysmenorrhea. MEASUREMENTS AND MAIN RESULTS: A total of 307 patients who underwent radiofrequency endometrial ablation were identified. After exclusions, 296 charts were examined, and 144 patients met our enrollment criteria. The mean age of the study cohort was 45.4 ± 6.2 years; 57 patients (40%) were African American, 16 (11%) had a body mass index (BMI) > 40, and 41 (29%) were of normal weight. Preoperative dysmenorrhea was reported by 100 patients (69%); 48 of these patients (48%) experienced resolution of symptoms postoperatively. Only 3 of the 44 patients (7%) without preoperative dysmenorrhea reported new-onset dysmenorrhea postoperatively. Significantly fewer patients had dysmenorrhea after compared to before radiofrequency ablation (55 of 144 [38%] vs 100 of 144 [69%]; p < .001). Resolution of dysmenorrhea after ablation was associated with reduction in bleeding volume (p = .048) but not with a reduction in frequency of bleeding (p = .12). CONCLUSIONS: Approximately one-half of women who undergo radiofrequency endometrial ablation to treat heavy menstrual bleeding who also have preoperative dysmenorrhea exhibit documented pain resolution after the procedure. Resolution of dysmenorrhea is more likely if menstrual flow volume is decreased postprocedure.

The future of obstetrics/gynecology in 2020: a clearer vision. Transformational forces and thriving in the new system.

Revamping the delivery of women's health care to meet future demands will require a number of changes. In the first 2 articles of this series, we introduced the reasons for change, suggested the use of the 'Triple Aim' concept to (1) improve the health of a population, (2) enhance the patient experience, and (3) control costs as a guide post for changes, and reviewed the transformational forces of payment and care system reform. In the final article, we discuss the valuable use of information technology and disruptive clinical technologies. The new health care system will require a digital transformation so that there can be increased communication, availability of information, and ongoing assessment of clinical care. This will allow for more cost-effective and individualized treatments as data are securely shared between patients and providers. Scientific advances that radically change clinical practice are coming at an accelerated pace as the underlying technologies of genetics, robotics, artificial intelligence, and molecular biology are translated into tools for diagnosis and treatment. Thriving in the new system not only will require time-honored traits such as leadership and compassion but also will require the obstetrician/gynecologist to become comfortable with technology, care redesign, and quality improvement.

The future of obstetrics/gynecology in 2020: a clearer vision: finding true north and the forces of change.

The pressure to transform health care has been building for many years, and many frameworks have been proposed for this transformation. The 'Triple Aim' concept of improving the health of the population, improving the experience of the patient, and controlling cost can be used as a guide post for the adoption of the necessary changes to thrive in a new construct of women's health care. Following these guiding principles should lead to improved clinical outcomes at affordable costs with high patient and provider satisfaction. The actual changes will come in the form of various 'transformational forces.' One of the driving forces will be conversion of the current payment structure from a fee-for-service model to value-based payments. In addition, the methods of care must be redesigned into a 'team-based' approach in which providers and patients use best practice protocols that are individualized to specific patient needs. Redesign will continue to drive consolidation of providers into larger groups to cover the cost of the needed infrastructure.

The future of obstetrics/gynecology in 2020: a clearer vision. Why is change needed?

External and internal pressures are causing rapid changes to the delivery of health care that markedly will influence the practice of obstetrics and gynecology. These changes can be divided into broad categories: (1) Burden of the high cost of current health care on society; (2) demographic changes in women that include aging, obesity, diversity, and chronic medical conditions; and (3) workforce changes that include growing provider shortages, inexperience, and desires for improved lifestyles. The combination of these factors has brought health care to a strategic inflection point where current practice methods will lead to an inability to meet the demand for health care because of increasing volume while simultaneously controlling costs and improving quality. This necessitates providing women's health care in a redesigned fashion for it to flourish in the new world of medicine.

Evaluation and management of adnexal mass in pregnancy.

With widespread use of ultrasound in early pregnancy, incidental adnexal masses are detected frequently. This article reviews the differential diagnosis, appropriate evaluation, and current treatment options for adnexal masses in pregnancy. With the increased sophistication of ultrasound, observation has become a more viable option. However, for those masses suspicious for malignancy, at risk for torsion, or clinically symptomatic, surgical management is warranted. With increasing numbers of successful laparoscopic procedures reported in pregnancy, laparoscopy appears to be a safe option with trained and experienced providers.

Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial.

OBJECTIVE: To estimate whether an organized, consistent program of dietary and lifestyle counseling prevents excessive weight gain in pregnancy. METHODS: This randomized controlled trial assigned women to receive either an organized, consistent program of intensive dietary and lifestyle counseling or routine prenatal care. The primary study outcome was the proportion of patients whose gestational weight gain was within the Institute of Medicine (IOM) guidelines. Secondary outcomes included mode of delivery, rate of operative vaginal delivery, neonatal weight, and the incidence of preeclampsia, gestational diabetes mellitus (GDM), vaginal/perineal lacerations, and shoulder dystocia. RESULTS: A total of 100 women were randomized to the study (lifestyle counseling 57, routine prenatal care 43). Baseline demographic characteristics were similar between the study groups. The lifestyle counseling group gained significantly less weight than did the routine prenatal care group (28.7+/-12.5 lb compared with 35.6+/-15.5 lb, P=.01). The routine prenatal care group had significantly more cesarean deliveries due to "failure to progress" (routine prenatal care 58.3% compared with lifestyle counseling 25.0%, P=.02). Across groups, patients who were not adherent to the IOM guidelines had significantly heavier neonates (adherent 3,203.2+/-427.2 g compared with not adherent 3,517.4+/-572.4 g, P<.01). Nulliparous women gained significantly more weight than did parous women (36.5+/-14.5 lb compared with 27.7+/-12.7 lb, P<.01). The most predictive factor of IOM adherence was having a normal prepregnancy body mass index. No statistically significant differences were noted between the groups in adherence to IOM guidelines, rate of cesarean delivery, preeclampsia, GDM, operative vaginal delivery, or vaginal lacerations. CONCLUSION: An organized, consistent program of dietary and lifestyle counseling did reduce weight gain in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00792480 LEVEL OF EVIDENCE: I.

Patient satisfaction with 3 methods of postpartum contraceptive counseling: a randomized, prospective trial.

OBJECTIVE: To compare patient satisfaction with 3 different postpartum contraceptive counseling methods. STUDY DESIGN: Randomized, prospective trial in an urban medical center. Patients were randomized to receive physician-patient counseling, written literature or an educational video. The main outcome variable was patient satisfaction with the contraceptive teaching method. Patient satisfaction was analyzed as a categorical variable and compared with chi2 tests. Secondary outcomes were compared with chi2 tests and ANOVA. RESULTS: Greater than 90% of patients in each arm were satisfied with the contraceptive counseling that they received. Patients receiving physician-patient counseling expressed a 99% satisfaction rate (p = 0.044). African American (98.2%) and Hispanic (93.5%) patients were more satisfied than Caucasian (83.3%) patients (p = 0.026). Satisfaction with contraceptive counseling decreased with age. CONCLUSION: An organized program of contraceptive counseling provides adequate information for patients to be comfortable with their decision about their postpartum contraceptive method. Patients were most satisfied with physician counseling.

Does response to hormonal therapy predict presence or absence of endometriosis?

STUDY OBJECTIVE: We sought to determine whether relief of chronic pelvic pain symptoms with hormonal treatment is predictive of presence or absence of endometriosis or location of endometriosis within the pelvis. DESIGN: A retrospective, chart review (Canadian Task Force classification II-3). SETTING: A private practice endometriosis referral center. PATIENTS: Patients undergoing laparoscopy for pelvic pain with at least 3 months of previous hormonal treatment. INTERVENTIONS: Laparoscopy. MEASUREMENTS AND MAIN RESULTS: Response to hormonal treatment was ascertained by patient report in medical records. Presence and location of endometriosis was recorded based on operative findings and pathology reports. In all, 486 patients with chronic pelvic pain were identified, of whom 104 met our inclusion criteria. Endometriosis was diagnosed at laparoscopy in 88 (85%) patients. Endometriosis was identified at laparoscopy in 46 (81%) of 57 patients who failed to respond to hormonal therapy compared with 41 (87%) of 47 patients who previously responded to hormonal therapy (p = .37). Using final pathology as basis of diagnosis, 31 (67%) of 46 responders, and 39 (68%) of 57 nonresponders had endometriosis (p = .91). When data were analyzed by anatomic site of endometriosis, no significant difference was noted in response to preoperative hormonal therapy. CONCLUSION: Relief of chronic pelvic pain symptoms, or lack of response, with preoperative hormonal therapy is not an accurate predictor of presence or absence of histologically confirmed endometriosis at laparoscopy. Patients with chronic pelvic pain may benefit from laparoscopy and no judgment regarding diagnosis should be made without this evaluation.

Laparoscopic Burch colposuspension.

PURPOSE OF REVIEW: This review will describe the recent literature regarding laparoscopic Burch colposuspension. RECENT FINDINGS: A 2006 Cochrane review found laparoscopic Burch colposuspension to be equivalent to open Burch colposuspension regarding subjective cure rate, but a reduced objective cure rate was reported. Three subsequent randomized trials have not identified any significant difference between the two procedures with respect to subjective or objective cure rates. Three additional prospective cohorts found cure rates of 76-95%. Another randomized controlled trial found laparoscopic Burch colposuspension with mesh and staples to be inferior to using sutures. There have been no new trials comparing laparoscopic Burch colposuspension and tension-free slings since the Cochrane review. SUMMARY: Laparoscopic Burch colposuspension is an effective treatment for stress urinary incontinence and is equivalent to open Burch colposuspension. Success is affected by the surgeon's experience and surgical technique. No difference in subjective cure rates has been identified in comparison with tension-free slings; however, objective cure rates favor tension-free slings. We believe that laparoscopic Burch colposuspension is the procedure of choice in women undergoing pelvic-floor repair and concomitant retropubic surgery, and in young women, because it avoids the potential complications of mesh. More research comparing the two procedures is indicated.

Laparoscopic supracervical hysterectomy.

Laparoscopic supracervical hysterectomy is a minimally invasive procedure that was developed during the 1990s as a treatment for abnormal uterine bleeding. The literature regarding this procedure, mainly case series and retrospective comparisons, suggests that laparoscopic supracervical hysterectomy results in reduced operating time and blood loss and a quicker return to normal activity, compared with laparoscopic-assisted vaginal hysterectomy. A randomized, controlled trial that compared laparoscopic supracervical hysterectomy with hysteroscopic endometrial resection found that laparoscopic supracervical hysterectomy resulted in significantly better patient satisfaction at 2 years for similar costs. Unfortunately, there are no randomized trials that have compared laparoscopic supracervical hysterectomy to vaginal or abdominal hysterectomy. Given the lack of appropriate randomized, controlled trials and the limitations of the existing research, the laparoscopic supracervical hysterectomy's true value and appropriate clinical indications remain unknown. Well-designed randomized, controlled trials that compare laparoscopic supracervical hysterectomy with laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy, and total abdominal hysterectomy, with attention to short- and long-term morbidity, postoperative vaginal bleeding, postoperative cervical disease, sexual function, urinary symptoms, and pelvic prolapse are needed. The purpose of this article was to review the existing literature regarding laparoscopic supracervical hysterectomy and to evaluate the evidence regarding the proposed risks and benefits of the procedure.

It's time to challenge surgical dogma with evidence-based data.

Surgical training is an apprenticeship with surgical techniques passed from one physician to another. Often these techniques are based more on surgical dogma than scientific evidence. Despite surgical dogma to the contrary, electrocautery is the preferred technique for wound creation, and peritoneal closure has no significant advantage over nonclosure. No method of handling the subcutaneous tissue is clearly superior; however, suture closure appears to have some advantages in preventing wound disruption. Subcuticular suture closure results in less pain and better patient satisfaction, and it is more cost-effective than surgical staples. These surgical techniques, as well as many others, need to be subjected to rigorous, randomized prospective trials. It is incumbent on each physician to ensure that his or her surgical techniques are evidence based and not simply the result of adherence to surgical dogma.