Focus for the future: tackling the 'pelvic pain' problem in gynecologic practice - an interactive session

OBJECTIVE

The clinical management of women with chronic pelvic pain (CPP) and endometriosis involves important issues that exist at the interface between these two conditions.

METHODS

To address these issues, an interactive session was convened to discuss an empiric algorithmic protocol for the clinical management of CPP and endometriosis presented during the Takeda-sponsored session as part of the XVI FIGO World Congress of Gynecology and Obstetrics and to monitor the audience response to this approach.

RESULTS

Approximately one-third of the audience responded that they would definitely try this method, approximately 18% were already using it, and approximately 21% would be fairly likely to try it. Thirty percent of the audience was not convinced that the empiric approach is the best management strategy.

CONCLUSION

The advantages of this management strategy should be carefully considered, and discussed with colleagues who do think it is the reasonable treatment approach in selected cases.

The association between deprivation levels, attendance rate and triage category of children attending a children's accident and emergency department

OBJECTIVE

To determine the relation between deprivation category, triage score and accident and emergency (A&E) attendance for children under the age of 13.

DESIGN

Retrospective study of all children attending an A&E department over one year.

SETTING

A paediatric teaching hospital in Edinburgh.

SUBJECTS

All children attending the A&E department who had a postcode and a triage score documented on attendance. The postcode was used to determine the deprivation category and the triage scored the severity of illness or injury.

MAIN OUTCOME MEASURE

The relation between deprivation category, triage score and frequency of attendance.

RESULTS

There is a trend towards increased attendance in all triage categories for deprivation categories 6 and 7.

CONCLUSIONS

Attendance at A&E is not only related to severity of injury but also to deprivation category. The reason why people from disadvantaged areas attend more frequently needs further evaluation.

The carriage of pro-inflammatory cytokine gene polymorphisms in recurrent pregnancy loss

PROBLEM

Recurrent pregnancy loss (RPL) affects 2-4% of couples, and remains largely unexplained. Recent studies have examined the role of cytokines in the maintenance of normal pregnancy, which is linked with an increased expression of Th2 cytokines. Overexpression of Th1 cytokines is associated with RPL. Knowing that functional polymorphisms exist for certain cytokines, it has therefore been suggested that women with RPL may have a genetic predisposition to overexpress Th1 cytokines.

METHOD OF STUDY

The genes for interleukin-1 beta (IL-1beta) and tumor necrosis factor alpha (TNF-alpha) carry functional gene polymorphisms. In both cases these are biallelic polymorphisms that can be detected by polymerase chain reaction followed by restriction fragment length polymorphism. The aim of this pilot study was to assess whether carriage of the rarer alleles (TNF*2 and IL-1B*2) could act as independent risk factors in recurrent miscarriage.

RESULTS

We found an increased incidence in the carriage of TNF*2, more pronounced in those women with two or more miscarriages. Carriage of the IL-1B*2 either alone or in association with TNF*2 was not associated with recurrent miscarriage.

CONCLUSION

There may be a role for these cytokine gene polymorphisms in RPL.

Developing a 'consultation quality index' (CQI) for use in general practice

BACKGROUND

The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations.

OBJECTIVES

The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure.

METHODS

The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated.

RESULTS

CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes.

CONCLUSIONS

We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

A randomised comparison and economic evaluation of laparoscopic-assisted hysterectomy and abdominal hysterectomy

OBJECTIVES

To determine the safety, cost effectiveness and effect on quality of life of laparoscopic-assisted vaginal hysterectomy (LAVH) compared with total abdominal hysterectomy (TAH) in the management of benign gynaecological disease.

DESIGN

Randomised controlled trial and economic evaluation.

SETTING

Three hospitals in the West of Scotland.

PARTICIPANTS

Two hundred women scheduled for an abdominal hysterectomy for benign gynaecological disease.

MAIN OUTCOME MEASURES

Conversion rate of LAVH to TAH, complication rates, NHS resource use and costs, quality of life using EuroQol 5 D visual analogue scale, and achievement of milestones.

RESULTS

The overall incidence of operative complications was 14% in the TAH group and 8% in the LAVH group, with an 8% conversion rate. Length of operation was significantly greater in the women having LAVH at 81 +/- 30 min vs 47 +/- 16 min (P < 0.001). There was no difference in analgesic requirements between the groups although there was a significantly shorter hospital stay for those having LAVH. The rate of post-surgery recovery, satisfaction with operation and quality of life at four weeks post-operative were similar in the two groups of women. LAVH was significantly more expensive than TAH and remained more expensive for all but the most extreme scenario.

CONCLUSIONS

This study demonstrates that despite the decreased length of hospital stay, LAVH is more expensive than TAH. In addition, recovery following operation and patient satisfaction were not affected by the route chosen. It is unlikely that LAVH represents an efficient use of NHS resources.

Pre-eclampsia

Pre-eclampsia is associated with significant morbidity and mortality for mother and baby, but it resolves completely post partum. Despite a steady reduction in maternal mortality from the disorder in more developed countries, it remains one of the most common reasons for a woman to die during pregnancy. The disorder starts with a placental trigger followed by a maternal systemic response. Because both this systemic response and the woman's reaction to it are inconsistent, the clinical presentation varies in time and substance, with many different organ systems affected. With the increasing understanding of the disease process, there have been advances in management, such as antihypertensive therapy, magnesium sulphate, and fluid restriction.

Evidence of a T(H) 1 type response associated with recurrent miscarriage

OBJECTIVE

To determine whether the T(H) 1 cytokine interferon (IFN)-gamma is associated with miscarriage whereas the T(H) 2 cytokine interleukin (IL)-10 is associated with successful pregnancy.

DESIGN

Controlled clinical study.

SETTING

Healthy volunteers in an academic setting.

PATIENT(S)

Group 1 comprised 10 nonpregnant women; group 2, 10 first-trimester primigravid women; group 3, 10 first-trimester primigravid women suffering spontaneous abortion; and group 4, 10 first-trimester pregnant women with a history of miscarriage. All women were pregnant at the time of sampling, but 5 miscarried later in the first trimester.

INTERVENTION(S)

None of the patients received any medication.

MAIN OUTCOME MEASURE(S)

Serum levels of IL-10 and IFN-gamma.

RESULT(S)

Levels of IL-10 were significantly raised in normal pregnancy. Levels of IFN-gamma were raised in the recurrent-miscarriage group as compared with normal pregnancy. When patients in group 4 were divided into those whose pregnancies went to term and those who miscarried, we found that successful pregnancy was associated with a statistically significant increase in IL-10, whereas miscarriage was associated with significantly increased levels of IFN-gamma.

CONCLUSION(S)

These results support the view that miscarriage is associated with a T(H) 1 type response.

Vascular endothelial growth factor (VEGF) in breast cancer: comparison of plasma, serum, and tissue VEGF and microvessel density and effects of tamoxifen

The assessment of angiogenesis in breast cancer is of importance as a key indicator of survival and response to therapy. Circulating vascular endothelial growth factor (VEGF) measurements may provide a less subjective analysis than microvessel density (MVD) or immunohistochemical analysis of VEGF expression; however, most studies have used serum, which is now known to largely reflect platelet-derived VEGF concentrations. This study examined for the first time both plasma (VEGFp) and serum (VEGFs) VEGF concentrations in 201 blood samples from pre- and postmenopausal healthy controls and from patients with benign breast disease, localized breast cancer, breast cancer in remission, or metastatic breast cancer and related these to other clinicopathological markers. VEGFp but not VEGFs concentrations of patients with localized disease were significantly elevated compared with normal controls (P = 0.016). Patients with metastatic disease had higher VEGFp and VEGFs levels than normal controls (P < 0.001, P = 0.044 respectively), and higher VEGFp, but not VEGFs, than patients with benign disease (P = 0.009) and patients with localized disease (P = 0.004). However, the highest VEGFp and VEGFs concentrations were seen in patients in remission compared with normal controls (P < 0.001 and P = 0.008, respectively). VEGFp concentrations in patients in remission were also higher than in patients with benign disease (P = 0.01) or patients with localized disease (P = 0.005). Tamoxifen treatment was significantly associated with higher circulating and platelet-derived VEGF levels. Circulating VEGF did not correlate with any clinicopathological factor, including MVD or VEGF expression. VEGF expression was significantly correlated with estrogen receptor status and inversely correlated with tumor grade. MVD correlated with tumor size. Tamoxifen-induced increases in VEGF may be important in clinical prognosis or associated pathologies.

The Drosophila melanogaster sex determination gene sisA is required in yolk nuclei for midgut formation

During sex determination, the sisterlessA (sisA) gene functions as one of four X:A numerator elements that set the alternative male or female regulatory states of the switch gene Sex-lethal. In somatic cells, sisA functions specifically in sex determination, but its expression pattern also hints at a role in the yolk cell, a syncytial structure believed to provide energy and nutrients to the developing embryo. Previous studies of sisA have been limited by the lack of a null allele, leaving open the possibility that sisA has additional functions. Here we report the isolation and molecular characterization of four new sisA alleles including two null mutations. Our findings highlight key aspects of sisA structure-function and reveal important qualitative differences between the effects of sisA and the other strong X:A numerator element, sisterlessB, on Sex-lethal expression. We use genetic, expression, clonal, and phenotypic analyses to demonstrate that sisA has an essential function in the yolk nuclei of both sexes. In the absence of sisA, endoderm migration and midgut formation are blocked, suggesting that the yolk cell may have a direct role in larval gut development. To our knowledge, this is the first report of a requirement for the yolk nuclei in Drosophila development.

A double-blind randomised trial of leuprorelin acetate prior to hysterectomy for dysfunctional uterine bleeding

OBJECTIVE

To evaluate the use of pre-operative leuprorelin acetate for reducing the morbidity from hysterectomy for nonfibroid menorrhagia.

DESIGN

A double-blind, randomised, placebo-controlled trial.

SETTING

Gynaecology department in a large university teaching hospital.

SAMPLE

Fifty-one women without uterine fibroids awaiting abdominal or vaginal hysterectomy for dysfunctional uterine bleeding.

METHODS

Participants received leuprorelin acetate or placebo for eight weeks prior to hysterectomy.

MAIN OUTCOME MEASURES

Operative blood loss, operative difficulty, first day morphine use, speed of return to 'normal health'.

RESULTS

The study and control groups were similar as regards prognostic factors. Two women in the study group withdrew because of side-effects. Although a 34% reduction in uterine volume was seen in those treated with leuprorelin, there were no significant differences in operative blood loss (183 mL in the study group vs 285 mL in controls, P = 0.27), operation time (39 vs 49 min, P = 0.64) or operative difficulty (visual analogue scale 3.0 vs 4.0, P = 0.09). Furthermore, there was no difference between the groups in post-operative morbidity or rate of recovery.

CONCLUSIONS

Treating women with leuprorelin acetate for 8 weeks prior to surgery for nonfibroid menorrhagia has no significant operative or post-operative benefits.

Randomised clinical trials of fish oil supplementation in high risk pregnancies. Fish Oil Trials In Pregnancy (FOTIP) Team

OBJECTIVE

To test the postulated preventive effects of dietary n-3 fatty acids on pre-term delivery, intrauterine growth retardation, and pregnancy induced hypertension.

DESIGN

In six multicentre trials, women with high risk pregnancies were randomly assigned to receive fish oil (Pikasol) or olive oil in identically-looking capsules from around 20 weeks (prophylactic trials) or 33 weeks (therapeutic trials) until delivery.

SETTING

Nineteen hospitals in Europe.

SAMPLES

Four prophylactic trials enrolled 232, 280, and 386 women who had experienced previous pre-term delivery, intrauterine growth retardation, or pregnancy induced hypertension respectively, and 579 with twin pregnancies. Two therapeutic trials enrolled 79 women with threatening pre-eclampsia and 63 with suspected intrauterine growth retardation.

INTERVENTIONS

The fish oil provided 2.7 g and 6.1 g n-3 fatty acids/day in the prophylactic and therapeutic trials, respectively.

MAIN OUTCOME MEASURES

Preterm delivery, intrauterine growth retardation, pregnancy induced hypertension.

RESULTS

Fish oil reduced recurrence risk of pre-term delivery from 33% to 21% (odds ratio 0.54 (95% CI 0.30 to 0.98)) but did not affect recurrence risks for the other outcomes (OR 1.26; 0.74 to 2.12 and 0.98; 0.63 to 1.53, respectively). In twin pregnancies, the risks for all three outcomes were similar in the two intervention arms (95% CI for the three odds ratios were 0.73 to 1.40, 0.90 to 1.52, and 0.83 to 2.32, respectively). The therapeutic trials detected no significant effects on pre-defined outcomes. In the combined trials, fish oil delayed spontaneous delivery (proportional hazards ratio 1.22; 1.07 to 1.39, P = 0.002).

CONCLUSIONS

Fish oil supplementation reduced the recurrence risk of pre-term delivery, but had no effect on pre-term delivery in twin pregnancies. Fish oil had no effect on intrauterine growth retardation and pregnancy induced hypertension, affecting neither recurrence risk nor risk in twin pregnancies.

Malignant primary hypertension in pregnancy treated with lisinopril

OBJECTIVE

To report a case of a patient treated with an angiotensin-converting enzyme (ACE) inhibitor with a good neonatal outcome.

CASE REPORT

A 39-year-old African-Caribbean patient who had chronic hypertension presented at 18 weeks' gestation with acute hypertension. She was being treated for chronic hypertension with lisinopril, but had self-discontinued treatment. Attempts to control her hypertension with labetolol, nifedipine, and methyldopa were ineffective. She was therefore offered termination of pregnancy so treatment with lisinopril could be restarted. The patient elected to continue with the pregnancy in spite of the fetal risks associated with the use of an ACE inhibitor. She was delivered of a girl at 26 weeks' gestation. The baby initially had renal failure and also developed acute necrotizing enterocolitis. The renal failure improved simultaneously with the latter complication, and it is postulated that there was enteric excretion of lisinopril. The baby was discharged home on day 102 with no further complications.

DISCUSSION

ACE inhibitors are acceptable medications to use in the first trimester of pregnancy; however, fetal malformations and neonatal complications have been associated with their use later in pregnancy, and they have a perinatal mortality rate of 97/1000. Lisinopril is excreted in urine and feces unchanged, and its half-life is prolonged in anuric neonates. Peritoneal dialysis eliminates lisinopril; however, this neonate improved after treatment for necrotizing enterocolitis and simultaneous improvement in bowel function.

CONCLUSIONS

ACE inhibitors should not be used in pregnancy beyond the end of the first trimester. In exceptional cases, they may be indicated for the control of severe hypertension when the patient is refractory to other medications. The patient should be fully counseled about the adverse effect profile and neonatal outcome. This case report documents a successful outcome for mother and baby in these circumstances.

Severe pre-eclampsia and eclampsia

The mainstay of the management of severe pre-eclampsia is early referral, stabilization of the mother with antihypertensive therapy and anticonvulsants if required, full assessment of the mother and the baby, and delivery on the best day in the best way. It is to be remembered that delivery is the long-term cure, but most women get worse after delivery and most maternal deaths occur postpartum. It is important that doctors have the training to be aware of the dangers of this condition, guidelines to follow and senior support. Lowering blood pressure has been associated with a reduction in the mortality from cerebrovascular accident and early use of antihypertensive agents is beneficial to both mother and baby. The main cause of death is now pulmonary oedema, with renal failure a rare complication. It is important that, after delivery, vigilance is maintained and fluid replacement is given with care. It is better to 'run them dry' than to give fluid replacement that may encourage pulmonary oedema. Followup is required with counselling about what has happened and the prospects of recurrence.

1H NMR as a non-invasive probe of amniotic fluid in insulin dependent diabetes mellitus

Ten amniotic fluid samples obtained from third trimester pregnant women suffering from insulin dependant diabetes mellitus were analysed by 1H-NMR and compared to ten samples from a group of normal volunteers. A subset of the metabolites identified; valine, lactate, alanine, acetate, citrate and glucose were quantitated using standard addition methods. Apart from valine and citrate, a general diminution in the concentration of each of these species was found, especially glucose, in the diabetic group. The abnormally low glucose levels in the diabetic group are suggestive of infection in the patient group. However, the depressed lactate levels in the diabetic group suggest that in these cases the fetus was not subjected to stress.

Antioxidants: their role in pregnancy and miscarriage

The aim of this study was to examine the role of antioxidants within the normal menstrual cycle, in healthy pregnancy, and in women suffering first-trimester miscarriage. The antioxidants chosen comprised of two from peripheral blood-plasma thiol and ceruloplasmin-and two extracellular parameters-superoxide dismustase (SOD) and red cell lysate thiol. We found that antioxidant levels varied little throughout the menstrual cycle. Pregnancies that went successfully to term were associated with increased levels of ceruloplasmin and SOD early in the first trimester. These changes were thought to offer the cell protection from the damage caused by the increased oxidative stress associated with pregnancy. First-trimester miscarriage was associated with significantly reduced levels of SOD. A subgroup of patients who miscarried in their first pregnancy, but whose second pregnancies were successful, had higher levels of plasma thiol and significantly reduced levels of red cell lysate thiol in the on-going pregnancy compared to levels at the time of miscarriage. Miscarriage and pregnancy appear to be associated with increased oxidative stress. In a successful pregnancy, however, changes occurred within the peripheral blood that offered protection from oxidant attack.

Intramuscular opioids for maternal pain relief in labour: a randomised controlled trial comparing pethidine with diamorphine

OBJECTIVE

To compare the pain relief and side effects of intramuscular pethidine with intramuscular diamorphine in labour.

DESIGN

Double-blind randomised controlled trial.

SETTING

The labour ward in a UK teaching hospital.

PARTICIPANTS

Sixty-nine nulliparous women and 64 multiparous women in labour who requested narcotic analgesia and remained undelivered one hour after trial entry.

METHODS

Nulliparous women were randomised to receive either 150 mg intramuscular pethidine or 7.5 mg intramuscular diamorphine. Multiparous women were randomised to receive either 100 mg intramuscular pethidine or 5 mg intramuscular diamorphine. All participants received the anti-emetic prochloroperazine at the same time as the trial drugs.

MAIN OUTCOME MEASURES

Maternal analgesia assessed by a visual analogue score and verbal scales of pain intensity and pain relief, maternal sedation and vomiting, neonatal outcome assessed by Apgar scores and the need for resuscitation.

RESULTS

More women allocated to receiving pethidine than to diamorphine reported slight or no pain relief at 60 minutes after administration of these drugs (P = 0.03). This trend was repeated in most of the other measures for maternal analgesia. There was no difference in maternal sedation, but the incidence of vomiting within 60 minutes was lower for women who received diamorphine (P = 0.02). Pethidine was associated with lower Apgar scores at 1 minute (P < 0.05).

CONCLUSION

Intramuscular diamorphine in labour appears to have some benefits, compared with intramuscular pethidine, but the trial was small and further research, particularly into alternative opioids and long term effects on the infants is still needed.

Quality at general practice consultations: cross sectional survey

OBJECTIVES

To measure quality of care at general practice consultations in diverse geographical areas, and to determine the principal correlates associated with enablement as an outcome measure.

DESIGN

Cross sectional multipractice questionnaire based study.

SETTING

Random sample of practices in four participating regions: Lothian, Coventry, Oxfordshire, and west London.

PARTICIPANTS

25 994 adults attending 53 practices over two weeks in March and April 1998.

MAIN OUTCOME MEASURES

Patient enablement, duration of consultation, how well patients know their doctor, and the size of the practice list.

RESULTS

A hierarchy of needs or reasons for consultation was created. Similar overall enablement scores were achieved for most casemix presentations (mean 3.1, 95% confidence interval 3.1 to 3.1). Mean duration of consultation for all patients was 8.0 minutes (8.0 to 8.1); however, duration of consultation increased for patients with psychological problems or where psychological and social problems coexisted (mean 9.1, 9.0 to 9.2). The 2195 patients who spoke languages other than English at home were analysed separately as they had generally higher enablement scores (mean 4.5, 4.3 to 4.7) than those patients who spoke English only despite having shorter consultations (mean 7.1 (6. 9 to 7.3) minutes. At individual consultations, enablement score was most closely correlated with duration of consultation and knowing the doctor well. Individual doctors had a wide range of mean enablement scores (1.1-5.3) and mean durations of consultation (3. 8-14.4 minutes). Doctors' ability to enable was linked to the duration of their consultation and the percentage of their patients who knew them well and was inversely related to the size of their practice. At practice level, mean enablement scores ranged from 2.3 to 4.4, and duration of consultation ranged from 4.9 to 12.2 minutes. Correlations between ranks at practice level were not significant.

CONCLUSIONS

It may be time to reward doctors who have longer consultations, provide greater continuity of care, and both enable more patients and enable patients more.

The influence of donated gametes on the incidence of hypertensive disorders of pregnancy

Pregnancies achieved from oocyte, sperm or embryo donation are unique, since they have resulted from donor gametes that are immunologically foreign to the mother. Thus, studying the obstetric outcome of such pregnancies may shed some light on the pathophysiology of preeclampsia, particularly in women conceiving with donated embryos, since the entire fetal genome is allogenic in these pregnancies. In this retrospective cohort study, a total of 144 women were studied. Of these, 72 were infertility patients who had conceived as a result of sperm, ovum or embryo donation and the other 72 women were age- and parity-matched control patients who became pregnant with their own gametes, either spontaneously, or following intrauterine insemination with their partner's spermatozoa. Study patients were divided into three groups depending on the origin of the donated gametes. Group 1 consisted of pregnancies achieved by intrauterine insemination with washed donor spermatozoa (n = 33). Group 2 included women who conceived using donated oocytes (n = 27) and group 3 consisted of women who conceived as a result of embryo donation (n = 12). The incidence of pregnancy-induced hypertension in the donated gametes study group was 12.5% (9/72) compared with 2.8% (2/72) in the control group. In addition, pre-eclampsia was diagnosed in 18.1% (13/72) of the donated gametes study group compared to 1.4% (1/72) in the age- and parity-matched controls. The increased incidence of gestational hypertension in pregnancies resulting from donated gametes gives evidence for a maternal genetic component, with an equally strong fetal influence, in the complicated aetiology of gestational hypertension, and pre-eclampsia in particular.

Menopausal changes in the myometrium: an investigation using a GnRH agonist model

Thirty-four premenopausal women were randomized to receive 3.75 mg of leuprorelin acetate depot or placebo for 8 weeks before hysterectomy. Postoperatively, the myometrium was examined by two independent pathologists and the pathologic features were graded. Computer analysis was used to assess myometrial cellularity and arterial wall structure (on hematoxylin and eosin-stained sections) and vascularity (on sections immunostained for Factor VIII-related antigen). The cellularity of the gonadotrophin-releasing hormone agonist-treated myometrium was higher than the controls with less stromal edema. Focal myometrial hyalinization was present in a minority of cases, all in the gonadotrophin-releasing hormone agonist-treated cases. The arteries in the gonadotrophin-releasing hormone agonist-treated uteri underwent atrophy of the tunica media and had significantly more perivascular fibrosis. The number of vessels per 100 myocytes also was decreased. Hypoestrinism secondary to leuprorelin treatment leads to myocyte atrophy, decreased stromal edema, atrophy of the arcuate arteries, and decreased myometrial vascularity.

Decreasing estrogen in nonpregnant women lowers uterine myometrial type I nitric oxide synthase protein expression

OBJECTIVE

Our purpose was to study the effect of estrogen on myometrial nitric oxide synthase.

STUDY DESIGN

Twenty-four women were randomly assigned to treatment with gonadotropin-releasing hormone agonist or placebo for 8 weeks before hysterectomy, at which time samples of myometrium were collected and the serum levels of estrogen, nitrate, and nitrite measured. Myometrial nitric oxide synthase was measured with the arginine-citrulline assay. The levels of endothelial nitric oxide synthase and neuronal nitric oxide synthase were determined by Western blot analysis.

RESULTS

Myometrial nitric oxide synthase was 88% calcium dependent but only partially calmodulin dependent. Women treated with gonadotropin-releasing hormone agonist had postmenopausal levels of estradiol and had significantly lower levels of myometrial neuronal nitric oxide synthase than those in the control group. Total, endothelial, and inducible nitric oxide synthase levels in the myometrium were unchanged, as were serum nitrite and nitrate levels.

CONCLUSION

Neuronal nitric oxide synthase is regulated in the myometrium by estrogen. Myometrial nitric oxide synthase is not all calmodulin dependent; this may represent the activity of a novel nitric oxide synthase isoform.

GnRH analogue in everyday gynecology: is it possible to rationalize its use?

BACKGROUND

The study was an audit of patients who attended the Menstrual Disorders Clinic at Glasgow Royal Infirmary over a five year period, and received gonadotrophin-releasing hormone analog (GnRHa). We aimed to identify the clinical indications for the use of GnRHa, and the effect of the latter in terms of symptom resolution and ultimate outcome. We aim to use this information to formulate a strategy for the use of GnRHa by targeting this expensive therapy to those situations where maximum benefit will be achieved.

METHODS

A retrospective case review analysis of 201 patients.

RESULTS

Thirty-eight percent of women presented with pelvic pain, 33% with disordered menstruation and 26% with premenstrual symptomatology. Overall, 74% of patients reported a beneficial effect of GnRHa. In the non-cyclical pelvic pain group, those patients with adhesions constituted a much greater proportion of those who did not derive benefit from GnRHa than those who did (43% vs. 16%; p<0.05; data not shown). In those patients with disordered menses, there was no difference between the diagnosis in those who did or did not derive benefit from GnRHa. Also with the exception of endometrial preparation prior to ablation and in the correction of anemia, the ultimate outcome was no different in the two groups. Of the patients with premenstrual symptomatology, the greatest proportion of those deriving benefit from GnRHa (41%) ultimately had an operative resolution.

CONCLUSIONS

Our results enable us to use GnRHa as a first line in those clinical situations where maximum benefit will be achieved, either in terms of symptom resolution or as a tool to identify the most appropriate therapeutic option. We can therefore rationalize our prescribing both to the benefit of the patient and to our budget.

Thyroid antibody titer and avidity in patients with recurrent miscarriage

OBJECTIVE

To determine whether the titer and avidity of the thyroid peroxidase antibody differs between pregnant women in their first trimester who have a history of recurrent miscarriage and whose pregnancies continue to term and those whose pregnancies fail again later in the first trimester.

DESIGN

Controlled clinical study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Pregnant women in their first trimester who had a history of recurrent miscarriage (> or = 3 miscarriages) and who were known to be positive for the thyroid peroxidase antibody.

INTERVENTION(S)

None of the patients received any medication.

MAIN OUTCOME MEASURE(S)

Thyroid peroxidase antibody titer and avidity (i.e., the net binding strength between antibody and antigen).

RESULT(S)

At the time of presentation, thyroid peroxidase antibody titer and avidity was significantly higher in those women who later miscarried compared with those whose pregnancies continued. In those whose pregnancies continued to term, titer and avidity declined as the pregnancy progressed.

CONCLUSION(S)

Autoimmunity plays a role in recurrent miscarriage. Among a group of patients who had had recurrent miscarriages, there appeared to be differences in the humoral response to the pregnancy between those whose pregnancies continued to term and those whose pregnancies failed again.