Long-term progestin-only contraceptives result in reduced endometrial blood flow and oxidative stress

CONTEXT

Because of their safety and efficacy, long-term progestin-only contraceptives (LTPOCs) are well-suited for women with restricted access to health care. However, abnormal uterine bleeding (AUB) causes half of all users to discontinue therapy within 12 months. Endometria of LTPOC-treated patients display aberrant angiogenesis with abnormally enlarged, thin-walled, fragile blood vessels, inflammation, and focal hemorrhage. In this study, similar effects were observed with a new third-generation implantable LTPOC.

OBJECTIVE

We hypothesized that LTPOC reduces uterine and endometrial blood flow, leading to hypoxia/reperfusion, which triggers the generation of reactive oxygen species. The latter induce aberrant angiogenesis, causing AUB.

DESIGN

Endometrial perfusion was measured by laser-Doppler fluxmetry in women requesting LTPOCs. Endometrial biopsies were obtained for in vivo and in vitro experiments.

SETTING

The study was conducted in the Yale University School of Medicine and Family-Planning Center in Western Australia.

PATIENTS

Seven women 18 yr or older requesting implantable LTPOCs were recruited in Western Australia.

INTERVENTION

Women received etonorgestrel implants.

MAIN OUTCOME

LTPOC treatment resulted in reduced endometrial perfusion and increased endometrial oxidative damage.

CONCLUSIONS

We propose that LTPOCs result in hypoxia reperfusion, which leads to aberrant angiogenesis resulting in AUB.

Mechanisms of irregular bleeding with hormone therapy: the role of matrix metalloproteinases and their tissue inhibitors

CONTEXT

Irregular bleeding is common in users of combined hormone therapy (HT) and often leads to invasive and expensive investigations to exclude underlying pathology. The mechanisms of HT-related bleeding are poorly understood. Endometrial matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are believed to regulate bleeding during the normal menstrual cycle and are known to be altered in breakthrough bleeding with progestogen-only contraception.

OBJECTIVE

The aim of this study was to determine how HT exposure alters endometrial production of MMP-1, -3, -9, and -14 and their tissue inhibitors TIMP-1, -2, -3, and -4 and to determine the relationship between MMP and TIMP production and bleeding patterns in HT users. Endometrial leukocytes regulating MMP production and activation were also assessed.

DESIGN

A prospective observational study was conducted between 2003 and 2005.

SETTING AND PATIENTS

The study occurred at a tertiary referral menopause clinic at King Edward Memorial Hospital, Western Australia, and included 25 postmenopausal women not taking HT and 73 women taking combined HT.

INTERVENTIONS

Endometrium was obtained during and outside bleeding episodes.

MAIN OUTCOME MEASURES

We assessed production of MMP-1, -3, -9, and -14 and their tissue inhibitors TIMP-1, -2, -3, and -4 and their relationship to bleeding patterns in HT users.

RESULTS

All MMPs studied, with the exception of MMP-9, were expressed at low levels in postmenopausal endometrium. Increases in both MMP-3 and -9 localization were seen in association with irregular bleeding, but these did not reach statistical significance. Endometrial production of TIMP-1 was significantly increased in association with bleeding. Endometrial leukocytes were not related to bleeding, with the exception of uterine natural killer cells, which were significantly increased during bleeding, as previously published.

CONCLUSIONS

Irregular bleeding in HT users is associated with a distinct pattern of MMP and TIMP production that differs from that seen in normal menstrual bleeding and from that seen in contraceptive-related breakthrough bleeding. This suggests that the endometrial balance between MMP and TIMP contributes to vascular breakdown with HT but by a different mechanism than that seen in normal menstruation or in breakthrough bleeding.

Medical treatment for early fetal death (less than 24 weeks)

BACKGROUND

In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment before 14 weeks has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for early pregnancy failure (anembryonic pregnancies or embryonic and fetal deaths before 24 weeks).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2005).

SELECTION CRITERIA

Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-random studies were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted unblinded.

MAIN RESULTS

Twenty four studies (1888 women) were included. Vaginal misoprostol hastens miscarriage (complete or incomplete) when compared with placebo: e.g. miscarriage less than 24 hours (two trials, 138 women, relative risk (RR) 4.73, 95% confidence interval (CI) 2.70 to 8.28), with less need for uterine curettage (two trials, 104 women, RR 0.40, 95% CI 0.26 to 0.60) and no significant increase in nausea or diarrhoea. Lower-dose regimens of vaginal misoprostol tend to be less effective in producing miscarriage (three trials, 247 women, RR 0.85, 95% CI 0.72 to 1.00) with similar incidence of nausea. There seems no clear advantage to administering a 'wet' preparation of vaginal misoprostol or of adding methotrexate, or of using laminaria tents after 14 weeks. Vaginal misoprostol is more effective than vaginal prostaglandin E in avoiding surgical evacuation. Oral misoprostol was less effective than vaginal misoprostol in producing complete miscarriage (two trials, 218 women, RR 0.90, 95% CI 0.82 to 0.99). Sublingual misoprostol had equivalent efficacy to vaginal misoprostol in inducing complete miscarriage but was associated with more frequent diarrhoea. The two trials of mifepristone treatment generated conflicting results. There was no statistically significant difference between vaginal misoprostol and gemeprost in the induction of miscarriage for fetal death after 13 weeks.

AUTHORS' CONCLUSIONS

Available evidence from randomised trials supports the use of vaginal misoprostol as a medical treatment to terminate non-viable pregnancies before 24 weeks. Further research is required to assess effectiveness and safety, optimal route of administration and dose. Conflicting findings about the value of mifepristone need to be resolved by additional study.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy and prolonged bleeding, pain, pressure symptoms and subfertility but are mostly benign. The traditional method of treatment has been surgery as long term medical therapies have not shown to be effective. Uterine artery embolization (UAE - complete occlusion of both the uterine arteries with particulate emboli) has been reported to be an effective and safe alternative in the treatment of menorrhagia and other fibroid-related symptoms in women not desiring future fertility, but thus far this evidence is based on case controlled studies and case reports.

OBJECTIVES

To review the benefits and/or harms from randomised controlled trials (RCTs) of uterine artery embolization (UAE) versus other interventions for symptomatic uterine fibroids.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched 10 August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, Issue 3, 2004), MEDLINE (January 1966 to November 2005) and EMBASE (January 1980 to November 2005). We also contacted authors of potential ongoing studies.

SELECTION CRITERIA

RCTs of UAE versus any medical or surgical therapy for symptomatic uterine fibroids.

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) assessed the trials and extracted the data independently. They also contacted the investigators of eligible RCTs for unpublished data.

MAIN RESULTS

Three trials were included in this review. Two RCTs compared UAE with abdominal hysterectomy in 234 women. Although the follow-up period was intended for two years, the available published results was only for six months follow-up. The second trial included 63 women comparing UAE with myomectomy in women who wished to preserve their fertility. The minimum follow-up reported was six months with a mean of 17 (+/- 9.3) months. The clinical success rate measured by improvement in fibroid-related symptoms e.g. menstrual loss was at least 85% in the UAE group from both trials. The mean dominant fibroid volume decreased by 30 to 46% in two trials. UAE significantly reduces length of hospital stay compared to surgery for either hysterectomy or myomectomy. Women undergoing UAE resumed routine activities sooner than those undergoing surgery. UAE was associated with a higher rate of minor post procedural complications such as vaginal discharge, post puncture haematoma and post embolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge, compared with hysterectomy. There were no major complication differences between the two groups. Three women in the myomectomy trial had elevated FSH levels post UAE indicating possible ovarian dysfunction.

AUTHORS' CONCLUSIONS

UAE offers an advantage over hysterectomy with regards to a shorter hospital stay and a quicker return to routine activities. There is no evidence of benefit of UAE compared to surgery (hysterectomy / myomectomy) for satisfaction. The higher minor complications rate after discharge in the UAE group as well as the unscheduled visits and readmission rates require more longer term follow-up trials to comment on its effectiveness and safety profile. There is currently an ongoing trial (REST, U. K.) and EMMY trial yet to report on the long term follow up, the results of which are awaited with interest.

A pilot study to assess the effect of three short-term treatments on frequent and/or prolonged bleeding compared to placebo in women using Implanon

BACKGROUND

The major side-effect of progestogen-only contraception is disruption of menstrual bleeding patterns, which can lead to a high incidence of early discontinuation. The aim of this study was to compare three treatments with placebo on the duration and recurrence of frequent and/or prolonged bleeding in Implanon users.

METHOD

Women between the ages of 18 and 45 years, who had used Implanon for > or =3 months and were experiencing prolonged or frequent bleeding patterns, were recruited at four Australian sites. Subjects were randomized to treatment using computer-generated random number table if they met the World Health Organization criteria for prolonged and/or frequent bleeding in the previous 90 days [Belsey, E.M., Pinol, A.P.Y. and Taskforce on Long-Acting Systemic Agents for Fertility Regulation, World Health Organization (1997) Contraception 55,57-65]. Treatments were: (1) mifepristone 25 mg given twice on day 1 followed by 4 days of twice daily placebo; (2) mifepristone 25 mg given twice on day 1 followed by 4 days of ethinyl estradiol (EE) 20 microg in the morning and placebo at night; (3) doxycycline 100 mg twice daily for 5 days; and (4) placebo twice daily for 5 days. Analysis was by intention to treat. The primary endpoint was the number of days of bleeding and spotting immediately following initiation of the 5 day course of each active therapy compared with placebo.

RESULTS

A total of 179 women was assigned to treatment. Both mifepristone in combination with EE and doxycycline alone were significantly more effective in stopping an episode of bleeding {mean 4. 3 days [confidence interval (CI) 3.5-5.2], and 4.8 days (CI 3.9-5.8) respectively} than mifepristone alone or placebo [5.9 days (CI 4.8-7.2) and 7.5 days (CI 6.1-9.1) respectively]. No effect on subsequent bleeding patterns was observed in any treatment group.

CONCLUSION

Both mifepristone plus EE and doxycycline alone were significantly more effective than placebo in terminating an episode of bleeding in women with prolonged and/or frequent bleeding using Implanon. We believe that the observed reduction in the number of bleeding days by almost 50% compared to placebo in both the mifepristone combination group and the doxycycline group demonstrates a clinically significant improvement in bleeding patterns and that further trials are needed to compare different combinations of therapy as well as multiple dosing regimens in order to establish which is the most effective treatment option. The effect of repeat administration or combinations of these preparations on long-term bleeding patterns requires further investigation.

Endometrial destruction techniques for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women; it can reduce their quality of life and cause anaemia. First-line therapy has traditionally been medical therapy but this is frequently ineffective. On the other hand, hysterectomy is obviously 100% effective in stopping bleeding but is more costly and can cause severe complications. Endometrial ablation is less invasive and preserves the uterus, although long-term studies have found that the costs of ablative surgery approach the cost of hysterectomy due to the requirement for repeat procedures. A large number of techniques have been developed to 'ablate' (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which are less time consuming. However, hysteroscopy may still be required as part of the ablative techniques and some of them must be considered to be still under development, requiring refinement and investigation.

OBJECTIVES

To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (April 2004). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to July 2004), EMBASE (1980 to July 2004), Current Contents (1993 to week 38, 2001), Biological Abstracts (1980 to June 2001), PsycLIT (1967 to August 2001), CINAHL (1982 to July 2004) and the metaregister of controlled trials and ISRCTN register (December 2004). We also searched reference lists of articles and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing different endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with the outcome, complications and need for further surgery or hysterectomy.

DATA COLLECTION AND ANALYSIS

The two review authors independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.

MAIN RESULTS

In the comparison of the newer non-hysteroscopic techniques (second generation) with the gold standard hysteroscopic ablative techniques (first generation) overall, surgery was an average of 15 minutes shorter (weighted mean difference (WMD) 14.9, 95% CI 10.1 to 19.7), local anaesthesia was more likely to be employed (odds ratio (OR) 8.3, 95% CI 3.9 to 17.5) and equipment failure was more likely (OR 4.2, 95% CI 1.3 to 13.8) with second-generation ablation. Women undergoing newer ablative procedures were less likely to have fluid overload, uterine perforation, cervical lacerations and hematometra than women undergoing the more traditional type of ablation and resection techniques (OR 0.13, 95% CI 0.04 to 0.5; OR 0.21, 95% CI 0.07 to 0.7; OR 0.12, 95% CI 0.05 to 0.3 and OR 0.25, 95% CI 0.09 to 0.7, respectively). However, women were more likely to have nausea and vomiting and uterine cramping (OR 2.3, 95% CI 1.5 to 3.4 and OR 1.8, 95% CI 1.1 to 2.9, respectively). Some differences were also found in amenorrhoea rates and satisfaction rates, but there did not appear to be a trend over time so these results may be due to chance.

AUTHORS' CONCLUSIONS

Endometrial ablation techniques continue to play an important role in the management of HMB. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the 'gold standard' of transcervical resection of the endometrium (TCRE) difficult. Most of the newer techniques are technically easier than hysteroscopy-based methods to perform. However, uterine perforation, which is the major complication of endometrial ablation, cannot be excluded without hysteroscopy. Overall, the existing evidence suggests that success rates and complication profiles of newer techniques of ablation compare favourably with TCRE, although technical difficulties with new equipment need to be ironed out.

Menopausal hormone therapy and irregular endometrial bleeding: a potential role for uterine natural killer cells?

CONTEXT

Irregular bleeding affects many users of combined menopausal hormone therapy (HT) and commonly leads to invasive and expensive investigations to exclude underlying malignancy. In most cases no abnormality is found.

OBJECTIVE

The main objective of this study was to explore the role of uterine natural killer (uNK) cells and their regulatory cytokine IL-15 in irregular bleeding in HT users.

DESIGN

This was a prospective observational study conducted between 2002 and 2004.

SETTING

The study was conducted in a tertiary referral menopause clinic at King Edward Memorial Hospital, Western Australia.

PATIENTS

Patients included 117 postmenopausal women taking combined HT.

INTERVENTIONS

Outpatient endometrial biopsies were taken during and outside bleeding episodes.

MAIN OUTCOME MEASURES

The relationship between endometrial uNK cells (CD56+) and bleeding patterns was measured. We also addressed the impact of HT exposure on uNK cell populations, the relationship between endometrial IL-15 expression and uNK cell populations, and killer Ig like receptor genotype in subjects with irregular bleeding.

RESULTS

Endometrial CD56+ uNK cells were significantly increased in biopsies obtained during bleeding episodes (P < 0.001), compared with HT users with no bleeding. The highest level of IL-15 expression was also seen in biopsies taken during bleeding. No clear relationship between killer Ig like receptor genotype and bleeding on HT was observed.

CONCLUSIONS

Little is known about the mechanisms underlying irregular bleeding in HT users. This is the first report of uNK cells and their association with regulating cytokines in postmenopausal endometrium and demonstrates a possible mechanism by which HT may induce irregular bleeding.

Excisional surgery versus ablative surgery for ovarian endometriomata

BACKGROUND

Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of endometriomata is favoured for as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.

OBJECTIVES

The objective of this review was to determine the most effective technique of treating an ovarian endometrioma; either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, with regard to relief of pain, recurrence of the endometrioma, recurrence of symptoms and the subsequent spontaneous pregnancy rate.

SEARCH STRATEGY

The reviewers searched the Cochrane Menstrual Disorders and Subfertility Group specialised register of trials (searched 15 Nov 2004), the Cochrane Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), MEDLINE (1966-Nov 2004), EMBASE (1980- Nov 2004) and reference lists of articles, the handsearching of relevant journals and conference proceedings and by contacting leaders in the field of endoscopic surgery throughout the world.

SELECTION CRITERIA

Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.

DATA COLLECTION AND ANALYSIS

Reviewers assessed eligibility and trial quality.

MAIN RESULTS

No randomised studies of the management of endometriomata by laparotomy were found. Two randomised studies of the laparoscopic management of ovarian endometriomata of greater than 3cm in size were included. Laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced rate of recurrence of the endometrioma (OR 0.41 CI 0.18-0.93), reduced requirement for further surgery (OR 0.21 CI 0.05-0.79), reduced recurrence rate of the symptoms of dysmenorrhoea (OR 0.15 CI 0.06-0.38), dyspareunia OR 0.08 CI 0.01-0.51) and non-menstrual pelvic pain (OR 0.10 CI 0.02-0.56). It was also associated with a subsequent increased rate of spontaneous pregnancy women who had documented prior sub-fertility (OR 5.21 CI 2.04-13.29).

AUTHORS' CONCLUSIONS

There is some evidence that excisional surgery for endometriomata provides for a more favourable outcome than drainage and ablation, with regard to the recurrence of the endometrioma, recurrence of symptoms and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However we found no data as to the effect of either approach in women who subsequently undergo assisted reproductive techniques.

Pasteurella multocida meningitis: case report and review of the literature

Pasteurella multocida forms part of the normal flora in the nasopharynx of many domestic and wild animals. Most human P. multocida infections are soft tissue infections due to animal bites. P. multocida meningitis is a rare condition. We report a case of P. multocida meningitis with a complicated outcome and review the literature of this condition.

286. The role of uterine natural killer cells in causing irregular bleeding in HT users

Menopausal hormone therapy (HT) causes irregular bleeding in up to 60% of user. This is extremely unpopular with patients, and commonly leads to invasive and expensive investigations to rule out underlying pelvic pathology. In most cases no cause is found. The aim of this study was to further elucidate the mechanisms of vascular fragility. Uterine NK cells are known to increase vascular fragility during the normal menstrual cycle. We hypothesise that HT is associated with an increase in uterine natural killer (uNK) cells. Eighty six endometrial biopsies were obtained from 59 postmenopausal users of continuous combined HT. Uterine NK cells were identified using immunohistochemistry as being CD56+. Image analysis was used to identify absolute number of CD56+ cells and their distribution within the stroma. Endometrial histology was classified using Noyes criteria. A statistically significant increase in endometrial uNK cell density was observed in HT users compared to postmenopausal women not using HT (P < 0.001). uNK cell populations were more marked in biopsies taken during a bleeding episode compared to those HT users with amenorrhoea (P = 031). uNK cells are a major regulator of endometrial vascular integrity and are known to be disrupted in irregular bleeding with progestin only contraceptives. This is the first study to report the presence of uNK cells in postmenopausal endometrium and the first to report a significant association between bleeding patterns and uNK cell density. We postulate that HT induces an increase in endometrial uNK cell populations and that their presence stimulates endometrial vascular fragility leading to bleeding.

246. A new look at menstrual repair: the role of CD34+ cells and CD56+ uterine NK cells

Endometrial regeneration occurs rapidly in a low estrogen environment without observable mitosis following menstruation. We have used a combination of hysteroscopy, scanning electron microscopy and immuno-histochemistry to re-examine this poorly understood process. Full thickness endometrial biopsies from 25 cycling women were used for immuno-histochemical analysis of the distribution of CD34+ and CD56+ cells. Histological appearances show that immediately preceding menstruation, a small population of CD34+ stromal cells are located in the basalis but that their numbers increase dramatically following the onset of menstruation, becoming the dominant stromal cell type at this time. Mean surface stromal count during menstruation of CD34+ cells was 5847/mm2 (n = 8) compared with pre-menstrual 108/mm2 (n = 7). Conversely CD56+ uNK cells in the endometrial stroma were minimal in the proliferative phase, mean 228/mm2 (n = 6) reaching a mean 2709/mm2 (n = 7) immediately pre-menstrually. There is a significant inverse correlation (at 0.01 level (2-tailed)) between CD34+ cells and CD56+ uNK cells across the menstrual cycle. We present additional scanning electron microscope and histological images to support the hypothesis that uterine endometrial repair may occur via a blood borne supply of CD34+ stem cells which differentiate in to elements of the endometrium; surface epithelium, glandular epithelium and stromal uNK cells. This hypothesis has profound clinical implications for the mechanisms and management of common gynaecological conditions resulting from abnormal endometrial repair and is contrary to the current understanding that uterine endometrium is replaced from basal remnants.

A three-dimensional study of endometrial microvessels in women using the contraceptive subdermal levonorgestrel implant system, norplant®

Recent evidence points towards a substantial disturbance of the process of angiogenesis within the endometrium in women who are exposed continuously to low dose contraceptive progestogens. This results in the patchy appearance of abnormally small and abnormally large, thin-walled vessels in the superficial regions of exposed endometrium. Three-dimensional pictures were developed from digitised images of serial tissue sections of endometrium in which microvascular endothelial cells were labelled with antibodies to the endothelial cell surface antigen, CD34 and their basement membranes labelled with anti-Collagen IV antibodies. Microvessels from endometrium exposed to continuous low-dose levonorgestrel from a subdermal implant system (Norplant) displayed considerable variations in size and shape. No spiral arterioles were identified. Some microvessels showed considerable dilatation, distortion and variability in the presence of surrounding basement membrane components. Other endothelial structures included narrow, solid cords of endothelial cells, without basement membranes, which often connected with normal or abnormal vessels containing lumens. Some areas, especially deeper in the tissue, contained microvessels of normal size and shape surrounded by basement membrane. These images have revealed an overall picture of great variability in superficial endometrial vascular structures in some women using a low-dose levonorgestrel implant system which appears substantially different from that seen in normal endometrium.

Changes in endometrial blood vessels in the endometrium of women with hormone replacement therapy-related irregular bleeding

BACKGROUND

Irregular bleeding affects up to 60% of hormone replacement therapy (HRT) users. The mechanism of this bleeding is not understood. Reduced endometrial microvascular integrity appears to underlie breakthrough bleeding in pre-menopausal women and the aim of this study was to establish whether similar changes are seen in HRT users and hence to elucidate a possible mechanism of irregular bleeding.

METHODS

Endometrium from 34 HRT users with amenorrhoea, irregular bleeding or regular bleeding was assessed for endometrial endothelial cell density (anti-CD34), number of blood vessels per mm(2), vascular basal lamina components (laminin, collagen IV and heparan sulphate proteoglycan) and in 32 subjects and 23 controls for perivascular smooth muscle alpha (SMA). Findings were compared with a control population of 29 post-menopausal women not using HRT, other sex steroids or tamoxifen and with no vaginal bleeding. Staining intensity was assessed in a blinded fashion in all immunohistochemical studies.

RESULTS

Four significant differences in endometrial blood vessels were observed between HRT users and controls: (i) a significantly lower density of endometrial endothelial cells (EC staining for CD34) per mm(2) was present in HRT users compared with controls (P < 0.001); (ii) endothelial cells (EC) were predominantly organized within blood vessels (83%) in controls but in HRT users EC were dispersed in the tissues with only 29% in organized vessels (P <0.001); (iii) supportive perivascular cell SMA was significantly reduced in 23 post-menopausal HRT users compared with 23 post-menopausal controls (n = 29, P = 0.013) and (iv) an atrophic or inactive histological pattern of endometrium was more frequently seen in the controls (P < 0.001).

CONCLUSIONS

These findings support the hypothesis that exposure to HRT profoundly alters endometrial blood vessels, reducing structural integrity thereby predisposing to irregular bleeding in HRT users.

Endometrial destruction techniques for heavy menstrual bleeding: a Cochrane review

This paper is based on a Cochrane review published in The Cochrane Library, issue 3, 2002 (see www.CochraneLibrary.net for information) with permission from The Cochrane Collaboration and Update Software. Cochrane reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the review.

BACKGROUND

The objective of this review was to compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce heavy menstrual bleeding (HMB) in premenopausal women.

METHODS

We searched the Cochrane Controlled Trials Register, Medline, Embase, Current Contents, Biological Abstracts, Psyclit and CINAHL. We also searched the specialized register of the Cochrane Menstrual Disorders and Subfertility Group and reference lists of articles, and contacted pharmaceutical companies and experts in the field. Randomized controlled trials comparing endometrial ablation techniques in women with a complaint of HMB without uterine pathology were selected. The outcomes included reduction of HMB, improvement in quality of life, operative outcomes, satisfaction with outcome, complications and need for further surgery. The two reviewers independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.

RESULTS

In comparing hysteroscopic techniques, the vaporizing electrode procedure was less difficult to perform [odds ratio (OR) = 0.25; 95% confidence interval (CI): 0.1, 0.7] and had less fluid deficit [weighted mean difference (WMD) = -258 ml; 95% CI: -342.1, -174.0] than transcervical resection of the endometrium (TCRE). The odds of fluid overload and equipment failure were higher (OR = 5.2; 95% CI: 1.5, 18.4 and OR = 6.0; 95% CI: 1.7, 20.9 respectively) for those women having laser treatment as compared with TCRE. In comparing traditional hysteroscopic endometrial ablation with the newer second generation techniques overall, the newer techniques took less time to perform (WMD = -11 min; 95% CI: -18.6, -2.6) and were more likely to be performed under local anaesthesia (OR = 7.6; 95% CI: 1.1, 52.7) but had a greater chance of equipment failure (OR = 4.1; 95% CI: 1.1, 15.0). The reduction in HMB did not differ significantly between any of the groups.

CONCLUSIONS

The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the 'gold standard' of TCRE difficult. Most of the newer techniques are performed blind and are technically easier than hysteroscopy-based methods. Overall, the existing evidence suggests that success rates and complication profile of newer techniques of ablation compare favourably with TCRE, although technical difficulties with new equipment need to be ironed out.

Clinical outcomes following percutaneous magnetic resonance image guided laser ablation of symptomatic uterine fibroids

BACKGROUND

Fibroids are common benign tumours of the uterus. Percutaneous magnetic resonance (MR) image guided laser ablation provides a minimally invasive, day-case alternative to surgery for the treatment of symptomatic fibroids.

METHODS

Women with symptomatic fibroids wishing to avoid surgery were treated with laser ablation. MR thermal mapping ensured that maximal safe energy was applied. Fibroid volume was measured at 3 and 12 months, menstrual blood loss was recorded before and after treatment and a menorrhagia outcomes questionnaire (MOQ) was used to assess satisfaction.

RESULTS

A total of 66 patients was treated. There was a significant (P < 0.001) reduction in mean fibroid volume of 31%. This was 41% at 1 year follow-up (P < 0.001). Measured menstrual blood loss in eight patients complaining of excessive bleeding was reduced (P = 0.012). The MOQ total outcome score was not as good as that seen in hysterectomy patients (P = 0.02) but the quality of life/satisfaction score was similar (P = 0.06).

CONCLUSION

We have used objective and subjective outcome measures to determine the efficacy of MR guided laser ablation for fibroids. Based on this limited study we are encouraged that this procedure may represent a minimally invasive alternative therapy for fibroids.

Surface vascularization and endometrial appearance in women with menorrhagia or using levonorgestrel contraceptive implants. Implications for the mechanisms of breakthrough bleeding

BACKGROUND

Women using progestogen-only contraceptives are commonly troubled by irregular bleeding. Endometrial vessel breakdown and repair is thought to be locally regulated under the indirect influence of sex steroids. Most information about endometrial vessels is derived from blind biopsies taken in an outpatient setting. Hysteroscopy allows in-vivo observation of the whole endometrial surface, including vessel morphology, distribution and areas of bleeding, as well as information about non-vascular structures that may not be accessible from biopsies.

METHODS

Hysteroscopies were performed on 34 women using the levonorgestrel contraceptive implant system (Norplant(TM)) and in a comparison group of 20 women complaining of menorrhagia due to ovulatory dysfunctional bleeding. The images were captured and vascular appearances assessed using image analysis.

RESULTS

The percentage of the superficial endometrium covered with blood vessels was found to be significantly greater in Norplant users compared with the comparison group (P = 0.0006). More superficial vessels were seen in those with recent frequent or prolonged bleeding and spotting (P < 0.0001). In Norplant users, but not in the comparison group, superficial vascular distribution was predominantly patchy (P < 0.0001). Unusual vascular appearances classified as 'neovascular' (P < 0.0001) and 'mosaic' (P < 0.0001) patterns were commonly seen in Norplant users but not in the comparison group. The hysteroscopic appearance of the endometrial epithelium, glands and stroma also differed between Norplant users and women with menorrhagia. Apparent shedding of the superficial endometrium was commonly seen by hysteroscopy in Norplant users during a bleeding episode (P < 0.0001). Prominent gland openings with thick mucus were commonly seen in Norplant users and small sessile polyps were seen in six cases.

CONCLUSIONS

These hysteroscopic observations provide further evidence that exposure to progestogens alters the superficial endometrial vasculature and may interfere with angiogenesis.

Apical barriers to airway epithelial cell gene transfer with amphotropic retroviral vectors

Gene transfer to airway epithelia with amphotropic pseudotyped retroviral vectors is inefficient following apical vector application. To better understand this inefficiency, we localized the expression of Pit2, the amphotropic receptor, in polarized human airway epithelia. Pit2 was expressed on both the apical and basolateral surfaces of the cells, suggesting that factors other than receptor abundance may limit apical gene transfer efficiency. Binding studies performed with radiolabeled amphotropic MuLV suggested that the apically applied virus binds to Pit2. Hypothetical barriers to retroviral gene transfer include the apical glycocalyx and other secreted products of epithelia. In this study, we demonstrated that sialic acid, keratan sulfate and collagen type V are present on the apical surface of well-differentiated human airway epithelia. While enzyme treatment reduced the abundance of these components, the treatment also decreased the transepithelial resistance to approximately 35% of the controls, suggesting that the epithelial integrity was impaired. To attain an airway epithelial culture with a modified apical surface and intact epithelial integrity, we utilized 100 mM 2-deoxy-D-glucose, a glycosylation inhibitor, to prevent the glycocalyx from reforming following enzyme treatment. This approach allowed the resistance, but not the apical glycocalyx to recover. Despite this physical modification of the cell surface, the amphotropic retroviral vector failed to transduce airway epithelia following apical application. These results suggest that factors other than apical receptor abundance and the glycocalyx inhibit amphotropic retroviral gene transfer in human airway epithelia.

Endometrial destruction techniques for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is a significant health problem in premenopausal women that can reduce quality of life and cause anaemia. First line therapy has traditionally been medical therapy but this is not always completely effective. Hysterectomy, often used after the failure of medical therapy, is 100% effective but is risky, costly and can cause complications. Endometrial ablation is less invasive, less costly and preserves the uterus. A large number of techniques have been developed to "ablate" (remove) the lining of the endometrium. The gold standard techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons. A number of newer techniques have recently been developed, most of which can be performed blind and are less time consuming. Many of these techniques are still under development, refinement and investigation.

OBJECTIVES

To compare the efficacy, safety and acceptability of methods used to destroy the endometrium to reduce HMB in premenopausal women.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (issue 4, 2001), Medline (1966 to September 2001), EmBase (1980 to August 2001), Current Contents (1993 to week 38, 2001), Biological Abstracts (1980 to June 2001), Psyclit (1967 to August 2001) and Cinahl (1982 to July 2001). We also searched the specialised register of the Cochrane Menstrual Disorders and Subfertility Group (August 2001). We also searched reference lists of articles and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing endometrial ablation techniques in women with a complaint of heavy menstrual bleeding without uterine pathology. The outcomes included reduction of heavy menstrual bleeding, improvement in quality of life, operative outcomes, satisfaction with outcome, complications and need for further surgery.

DATA COLLECTION AND ANALYSIS

The two reviewers independently selected trials for inclusion, assessed trials for quality and extracted data. Attempts were made to contact authors for clarification of data in some trials. Adverse events were only assessed if they were separately measured in the included trials.

MAIN RESULTS

In comparing hysteroscopic techniques, the vaporising electrode procedure was less difficult to perform (OR=0.25, 95%CI 0.1, 0.7) and had less fluid deficit (WMD=-258mls, 95% CI -342.1, -174.0) than TCRE. The odds of fluid overload and equipment failure were higher ((OR=5.2, 95% CI 1.5, 18.4) and (OR=6.0, 95% CI 1.7, 20.9) respectively) for those women having laser as compared to TCRE (transcervical resection of the endometriuim). In comparing traditional hysteroscopic endometrial ablation with the newer 2nd generation techniques overall, the newer techniques took less time to perform (WMD=-11mins, 95% CI -18.6, -2.6) and were more likely to be performed under local anaesthesia (OR=7.6, 95% CI 1.1, 52.7) but had a greater chance of equipment failure (OR=4.1, 95% CI 1.1, 15.0). The reduction in heavy bleeding did not differ significantly between any of the groups.

REVIEWER'S CONCLUSIONS

Endometrial ablation techniques continue to play an important role in the management of HMB. The rapid development of a number of new methods of endometrial destruction has made systematic comparisons between methods and with the "gold standard" of TCRE difficult. Most of the newer techniques are performed blind and are technically easier than hysteroscopy-based methods. Overall, the existing evidence suggests success rates and complication profile of newer techniques of ablation compares favourably with TCRE, although technical difficulties with new equipment need to be ironed out.