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Hagey JM, Drury KE, Kaplan S, Davidson BA, Morse JE. Contraceptive use following gestational trophoblastic disease: A systematic review. Contraception 2024; 137:110488. [PMID: 38763274 DOI: 10.1016/j.contraception.2024.110488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/10/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE To systematically review the effect of contraceptive methods following gestational trophoblastic disease (GTD) on timing of beta-human chorionic gonadotropin (hCG) remission, risk of post-molar gestational trophoblastic neoplasia (GTN), risk of unintended incident pregnancy, and interactions between contraceptive methods and disease treatment. STUDY DESIGN We conducted a search of primary literature with search terms related to GTD and contraception through April 2023 in PubMed and extrapolated our search to other platforms. Randomized controlled trials, observational studies and case reports were eligible for inclusion if they reported on patients with known GTD who received a contraceptive method for pregnancy prevention. Data was abstracted on our main outcomes of interest: timing of beta-hCG remission, risk of post-molar GTN, risk of unintended incident pregnancy, and interactions between contraceptive methods and cancer-directed systemic disease treatment (e.g., chemotherapy). At least two authors reviewed manuscripts at each screening stage with consensus reached before data extraction. Quality assessment checklists were used to assess risk of bias for the different study types. RESULTS Five thousand one hundred and five studies were identified in the database search, of which 42 were included for analysis. Eight thousand two hundred and ninety four participants were evaluated. Over half of the studies were case reports and only two were randomized controlled trials. While there was sparse data on all outcomes, no differences were noted in beta-hCG monitoring, risk of post-molar GTN or incident pregnancies between different contraceptive types. Interactions between contraceptive methods and cancer-directed systemic disease treatment (e.g., chemotherapy) or specific adverse events of contraceptive methods were not identified. CONCLUSIONS Data on contraceptive use following GTD is limited, but use of both hormonal and non-hormonal modern contraceptive methods appears safe. Counseling patients on the full range of contraceptive methods is important to help patients achieve their reproductive health goals and minimize the risk of disease progression through incomplete beta-hCG monitoring prior to future pregnancy. IMPLICATIONS Hormonal and non-hormonal contraceptive options may be used by patients following gestational trophoblastic disease without apparent changes in beta-hCG regression or risk of post-molar gestational trophoblastic neoplasia.
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Affiliation(s)
- Jill M Hagey
- Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States.
| | - Kerry E Drury
- Duke Women's Health Wake County North, Department of Obstetrics and Gynecology, Duke University, Wake Forest, NC, United States.
| | - Samantha Kaplan
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, United States.
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University, Durham, NC, United States.
| | - Jessica E Morse
- Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States.
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Gockley AA, Lin LH, Davis M, Melamed A, Rizzo A, Sun SY, Elias K, Goldstein DP, Berkowitz RS, Horowitz NS. Impact of clinical characteristics on human chorionic gonadotropin regression after molar pregnancy. Clinics (Sao Paulo) 2021; 76:e2830. [PMID: 34468539 PMCID: PMC8366901 DOI: 10.6061/clinics/2021/e2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study aimed to determine the effects of age, race/ethnicity, body mass index, and contraception on human chorionic gonadotropin (hCG) regression following the evacuation of a molar pregnancy. METHODS This was a retrospective cohort study of 277 patients with molar pregnancies between January 1, 1994 and December 31, 2015. The rate of hCG regression was estimated using mixed-effects linear regression models on daily log-transformed serum hCG levels after evacuation. RESULTS There were no differences in hCG half-lives among age (p=0.13) or race/ethnicity (p=0.16) groups. Women with obesity and hormonal contraceptive use demonstrated faster hCG regression than their counterparts (3.2 versus. 3.7 days, p=0.02 and 3.4 versus. 4.0 days, p=0.002, respectively). CONCLUSION Age and race/ethnicity were not associated with hCG regression rates. Hormonal contraceptive use and obesity were associated with shorter hCG half-lives, but with unlikely clinical significance. It is important to understand whether the clinical characteristics of patients may influence the hCG regression curve, as it has been proposed as a way to predict the risk of gestational trophoblastic neoplasia.
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Affiliation(s)
- Allison A. Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Corresponding author. E-mail:
| | - Lawrence H. Lin
- Department of Pathology, NYU School of Medicine, New York, USA
- Centro de Doencas Trofoblasticas, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Michelle Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
| | - Alexander Melamed
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Massachusetts, USA
| | - Anthony Rizzo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
| | - Sue Yazaki Sun
- Centro de Doencas Trofoblasticas, Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Kevin Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Donald P. Goldstein
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Ross S. Berkowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
| | - Neil S. Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School Boston, MA, USA
- Gynecologic Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, USA
- Trophoblastic Tumor Registry, New England Trophoblastic Disease Center, Boston, USA
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Cho HW, Ouh YT, Min KJ, Lee NW, Lee S, Song JY, Hong JH, Lee JK. The impact of previous cesarean section (C/S) on the risk for post-molar gestational trophoblastic neoplasia (GTN). Gynecol Oncol 2020; 156:606-610. [DOI: 10.1016/j.ygyno.2019.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
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Dantas PRS, Maestá I, Filho JR, Junior JA, Elias KM, Howoritz N, Braga A, Berkowitz RS. Does hormonal contraception during molar pregnancy follow-up influence the risk and clinical aggressiveness of gestational trophoblastic neoplasia after controlling for risk factors? Gynecol Oncol 2017; 147:364-370. [PMID: 28927899 DOI: 10.1016/j.ygyno.2017.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the influence of hormonal contraception (HC) on the development and clinical aggressiveness of gestational trophoblastic neoplasia (GTN) and the time for normalization of human chorionic gonadotropin (hCG) levels. METHODS A retrospective cohort study was conducted with women diagnosed with molar pregnancy, followed at the Rio de Janeiro Trophoblastic Disease Center, between January 2005 and January 2015. The occurrence of postmolar GTN and the time for hCG normalization between users of HC or barrier methods (BM) during the postmolar follow-up or GTN treatment were evaluated. RESULTS Among 2828 patients included in this study, 2680 (95%) used HC and 148 (5%) used BM. The use of HC did not significantly influence the occurrence of GTN (ORa: 0.66, 95% CI: 0.24-1.12, p=0.060), despite different formulations: progesterone-only (ORa: 0.54, 95% CI: 0.29-1.01, p=0.060) or combined oral contraception (COC) (ORa: 0.50, 95% CI: 0.27-1.01, p=0.60) or with different dosages of ethinyl estradiol: 15mcg (ORa, 1.33, 95% CI 0.79-2.24, p=0.288), 20mcg (ORa: 1.02, 95% CI: 0.64-1.65, p=0.901), 30mcg (ORa: 1.17, 95% CI: 0.78-1.75, p=0.437) or 35mcg (ORa: 0.77, 95% CI: 0.42-1.39, p=0.386). Time to hCG normalization ≥10weeks (ORa: 0.58, 95% CI: 0.43-1.08, p=0.071) or time to remission with chemotherapy≥14weeks (ORa: 0.60, 95% CI: 0.43-1.09, p=0.067) did not significantly differ among HC users when compared to patients using BM, when controlling for other risk factors using multivariate logistic regression. CONCLUSIONS The use of HC during postmolar follow-up or GTN treatment does not seem to increase the risk of GTN or its severity and does not postpone the normalization of hCG levels.
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Affiliation(s)
- Patrícia Rangel Sobral Dantas
- Department of Gynecology and Obstetrics, Botucatu Medical School, Postgraduate Program of Gynecology, Obstetrics and Mastology of São Paulo State University. Rubião Júnior District, Botucatu, São Paulo, Brazil; Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Izildinha Maestá
- Department of Gynecology and Obstetrics, Botucatu Medical School, Postgraduate Program of Gynecology, Obstetrics and Mastology of São Paulo State University. Rubião Júnior District, Botucatu, São Paulo, Brazil
| | - Jorge Rezende Filho
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Joffre Amin Junior
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil
| | - Kevin M Elias
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Neil Howoritz
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Antonio Braga
- Rio de Janeiro Trophoblastic Disease Center, Brazilian Association of Gestational Trophoblastic Disease, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Gynecology and Obstetrics, Maternity School, Postgraduate Program of Perinatal Health of Rio de Janeiro Federal University, 180 Laranjeiras St, Laranjeiras, Rio de Janeiro, RJ, Brazil; Department of Maternal-Child, Antonio Pedro University Hospital, Postgraduate Program of Medical Sciences of Fluminense Federal University, 303 Marquês do Paraná St, Centro, Niterói, Rio de Janeiro, Brazil.
| | - Ross S Berkowitz
- Department of Obstetrics and Gynecology and Reproductive Biology, Division of Gynecologic Oncology, New England Trophoblastic Disease Center, Donald P. Goldstein MD Trophoblastic Tumor Registry, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis St, Boston, MA, USA
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Braga A, Maestá I, Short D, Savage P, Harvey R, Seckl MJ. Hormonal contraceptive use before hCG remission does not increase the risk of gestational trophoblastic neoplasia following complete hydatidiform mole: a historical database review. BJOG 2015; 123:1330-5. [PMID: 26444183 DOI: 10.1111/1471-0528.13617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To re-evaluate the safety of hormonal contraceptives (HC) after uterine evacuation of complete hydatidiform mole (CHM). DESIGN Historical database review. SETTING Charing Cross Hospital Gestational Trophoblastic Disease Centre, London, United Kingdom. POPULATION Two thousand four hundred and twenty-three women with CHM of whom 154 commenced HC while their human chorionic gonadotropin (hCG) was still elevated, followed between 2003 and 2012. METHODS We compared time to hCG remission between HC users and nonusers. The relationship between HC use and gestational trophoblastic neoplasia (GTN) development was assessed. The relationship between HC use and a high International Federation of Gynecology and Obstetrics (FIGO) risk score was determined. MAIN OUTCOME MEASURES Time to hCG remission, risk of developing postmolar GTN and proportion of women with high FIGO risk score. RESULTS No relationship was observed between HC use with mean time to hCG remission (HC users versus non-users: 12 weeks in both, P = 0.19), GTN development (HC users versus non-users: 20.1 and 16.7%, P = 0.26) or high-risk FIGO score (HC users versus nonusers: 0% and 8%, P = 0.15). Moreover, no association between HC and GTN development was found, even when an age-adjusted model was used (OR = 1.37, 95% CI 0.91-2.08, P = 0.13). CONCLUSIONS The use of current HC is not associated with development of postmolar GTN or delayed time to hCG remission. Therefore, HC can be safely used to prevent a new conception following CHM regardless of hCG level. TWEETABLE ABSTRACT Non-concurrent cohort study to re-evaluate the safety of low dose HCs after uterine evacuation of CHM.
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Affiliation(s)
- A Braga
- Trophoblastic Disease Center, Maternity School of Rio de Janeiro Federal University and Antonio Pedro University Hospital at Fluminense Federal University, Rio de Janeiro, Brazil.,Postdoctoral Program of Science without Borders (Brazilian Government) - Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College School of Medicine, London, UK.,Postdoctoral Program of Gynecology, Obstetrics and Mastology Postgraduate of Botucatu Medical School, UNESP- São Paulo State University, Botucatu, São Paulo, Brazil.,Trophoblastic Disease Center, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP - São Paulo State University, Botucatu, São Paulo, Brazil
| | - I Maestá
- Trophoblastic Disease Center, Department of Gynecology and Obstetrics, Botucatu Medical School, UNESP - São Paulo State University, Botucatu, São Paulo, Brazil
| | - D Short
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College School of Medicine, London, UK
| | - P Savage
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College School of Medicine, London, UK
| | - R Harvey
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College School of Medicine, London, UK
| | - M J Seckl
- Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital, Imperial College School of Medicine, London, UK
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Postmolar gestational trophoblastic neoplasia: beyond the traditional risk factors. Fertil Steril 2015; 104:649-54. [DOI: 10.1016/j.fertnstert.2015.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 05/06/2015] [Accepted: 06/02/2015] [Indexed: 01/16/2023]
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Agarwal R, Teoh S, Short D, Harvey R, Savage PM, Seckl MJ. Chemotherapy and human chorionic gonadotropin concentrations 6 months after uterine evacuation of molar pregnancy: a retrospective cohort study. Lancet 2012; 379:130-5. [PMID: 22130490 PMCID: PMC3262143 DOI: 10.1016/s0140-6736(11)61265-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Indications for chemotherapy in gestational trophoblastic disease include raised human chorionic gonadotropin (hCG) concentrations 6 months after uterine evacuation of hydatidiform mole, even when values are falling. We aimed to establish whether chemotherapy is always necessary in these patients. METHODS We retrospectively identified women registered between January, 1993, and May, 2008, at Charing Cross Hospital, London, UK, who had persistently high hCG concentrations 6 months after evacuation of hydatidiform mole. Rates of hCG normalisation, relapse, and death were assessed in patients continued under surveillance and those who received chemotherapy after 6 months. We postulated that a surveillance policy would be clinically acceptable if hCG values returned to normal in 75% of patients or more. FINDINGS 76 (<1%) of 13,960 patients with hydatidiform moles had persistently high hCG concentrations of more than 5 IU/L 6 months after evacuation. 66 (87%) patients continued under surveillance and hCG values spontaneously returned to normal without chemotherapy in 65 (98%) of these patients. Values in one patient did not become normal because of chronic renal failure, but she remains healthy. Ten patients received chemotherapy, and hCG concentrations returned to normal in eight (80%) of these individuals (surveillance vs chemotherapy groups p=0·044) and remained slightly high (6-11 IU/L) in two without any associated clinical problems off treatment. We noted no significant differences between individuals in the surveillance and chemotherapy groups, apart from lower median hCG concentrations 6 months after evacuation in those under surveillance than in those given chemotherapy (13 IU/L, range 5-887, vs 157 IU/L, range 6-6438; p=0·004). Overall, there were no deaths in this series. INTERPRETATION A surveillance policy seems to be clinically acceptable in patients with low and declining concentrations of hCG 6 months after evacuation of hydatidiform mole. FUNDING National Commissioning Group, Imperial Experimental Cancer Medicine Centre, Imperial Biomedical Research Centre, and Cancer Research UK.
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Affiliation(s)
| | - Suliana Teoh
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Delia Short
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Richard Harvey
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Philip M Savage
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
| | - Michael J Seckl
- Imperial College London, London, UK
- Charing Cross Gestational Trophoblastic Disease Centre, Imperial College NHS Healthcare Trust, London, UK
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Abstract
Gestational trophoblastic disease encompasses a range of pregnancy-related disorders, consisting of the premalignant disorders of complete and partial hydatidiform mole, and the malignant disorders of invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumour. These malignant forms are termed gestational trophoblastic tumours or neoplasia. Improvements in management and follow-up protocols mean that overall cure rates can exceed 98% with fertility retention, whereas most women would have died from malignant disease 60 years ago. This success can be explained by the development of effective treatments, the use of human chorionic gonadotropin as a biomarker, and centralisation of care. We summarise strategies for management of gestational trophoblastic disease and address some of the controversies and future research directions.
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Affiliation(s)
- Michael J Seckl
- Department of Cancer Medicine, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
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Combined oral contraceptive and intrauterine device use among women with gestational trophoblastic disease. Contraception 2009; 80:363-71. [DOI: 10.1016/j.contraception.2009.03.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 03/23/2009] [Accepted: 03/25/2009] [Indexed: 11/18/2022]
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Adewole IF, Oladokun A, Fawole AO, Olawuyi JF, Adeleye JA. Fertility regulatory methods and development of complications after evacuation of complete hydatidiform mole. J OBSTET GYNAECOL 2009; 20:68-9. [PMID: 15512472 DOI: 10.1080/01443610063516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
In a prospective, simple randomised study, we evaluated the relative efficacy of hormonal (oral contraceptive pill) and non-hormonal (intrauterine contraceptive device) methods of contraception as fertility regulatory agents in patients with complete hydatidiform moles and assessed the development of complications and sequelae if any, following their use. Fifty-six patients each on oral contraceptive pills (OCP) and intrauterine contraceptive device (IUCD) were recruited into the study. Ten patients, six on OCP and four on IUCD discontinued for varying reasons. Five patients (two on OCP, and three on IUCD) developed a gestational trophoblastic tumour and were admitted for chemotherapy. There was no complication attributable to any of the methods.
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Affiliation(s)
- I F Adewole
- Department of Obstetrics and Gynaecology, College of Medicine, University College Hospital, Ibadan
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Berkowitz RS, Goldstein DP. Current management of gestational trophoblastic diseases. Gynecol Oncol 2009; 112:654-62. [DOI: 10.1016/j.ygyno.2008.09.005] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 09/03/2008] [Accepted: 09/05/2008] [Indexed: 10/21/2022]
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El-Shalakany AH, Kamel KM, Ismail AM, Salah L, El-Deen Fahmy SS, El-Deen Ammar E. Estrogen and progesterone receptors and telomerase enzyme immunohistochemical detection in gestational trophoblastic tumors. Int J Gynecol Cancer 2006; 16:1918-26. [PMID: 17009992 DOI: 10.1111/j.1525-1438.2006.00718.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The purpose of this study is to evaluate the immunohistochemical detection of telomerase enzyme and estrogen receptor (ER) and progesterone receptor (PGR) in gestational trophoblastic neoplasia (GTN) and its clinical significance. Formalin-fixed paraffin blocks for 30 patients (24 with molar pregnancy, 3 with choriocarcinoma, and 3 with placental site trophoblastic tumor) as cases and six products of conception samples from patients with incomplete abortion as controls were included in the study. Immunohistochemical detection of the telomerase catalytic protein and ER and PGR was carried out using streptavidin-biotin-peroxidase method. All control tissues were negative for telomerase and ER expression, while five of six were PGR positive. Significant positive telomerase expression was detected in all gestational trophoblastic tumors (three of six partial moles, 12 of 18 complete moles, three of three choriocarcinomas, and two of three placental site trophoblastic tumors). Nine of 24 molar pregnancies were followed by GTN. Molar pregnancies followed by GTN were associated with higher serum beta-hCG (human chorionic gonadotrophic hormone), larger uterine size for gestational age, negative ER expression, negative PGR expression, and positive telomerase expression. All patients with molar pregnancy with negative telomerase expression (9 of 24) showed spontaneous regression after evacuation. Positive telomerase expression and its immunohistochemical detection are associated with the development of GTN. Negative telomerase expression is highly predictive of postmolar spontaneous regression. Patients with molar pregnancies with negative telomerase expression can be saved the long-term follow-up. ER and PGR expression do not show a significantly different pattern in molar tissues, while negative expression is associated with developing GTN. Cautions on the use of postmolar hormonal contraception may be unjustified.
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Affiliation(s)
- A H El-Shalakany
- Gynaecologic Oncology Unit, Ain Shams University Medical School, Cairo, Egypt.
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Costa HLFF, Doyle P. Influence of oral contraceptives in the development of post-molar trophoblastic neoplasia—A systematic review. Gynecol Oncol 2006; 100:579-85. [PMID: 16297971 DOI: 10.1016/j.ygyno.2005.09.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Revised: 09/19/2005] [Accepted: 09/19/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Controversy exists regarding the use of oral contraceptives following hydatidiform mole and possible increased risk of persistent trophoblastic neoplasia. The purpose of this study is to perform a systematic review of the literature to assess the evidence for and against a possible link between oral contraceptive use and the need for chemotherapy after molar evacuation. METHODS We searched the computerized databases MEDLINE, EMBASE, Popline, Web of Sciences, LILACS and the Cochrane Controlled Trials Register, ISI Proceedings, performed a hand search of references and wrote to experts to identify randomized controlled trials and observational studies comparing oral contraceptives with other methods of contraception. Quality assessment included: concealment of allocation; intention to treat analysis; plus attrition bias for trials; confounding factors and selection bias for observational studies. We collected or calculated risk ratios for the incidence of gestational trophoblastic neoplasia and hCG regression time associated with oral contraceptive use. RESULTS Two randomized controlled trials were included for analysis. The risk ratios for OC use were similar in both studies: 0.69 (0.12-3.98) and 0.71 (0.46-1.10) respectively. No attempt to summarize these results was made because the studies observed different disease stages. In five of the seven observational studies, the risk ratio ranged from 0.57 (CI = 0.14-2.37) to 1.46 (CI = 0.56-3.79). CONCLUSION No clear evidence for an association between oral contraceptive use during post-molar follow-up period and the incidence of gestational trophoblastic neoplasia was found. Practitioners should no longer avoid their use because of a supposed effect which we have shown here to be unsupported by evidence in the literature.
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Macdonald R, Kirwan J, Thomson C, Hancock B, Everard J, Tidy J. Oestradiol and FSH in gestational trophoblastic disease: a prospective analysis of their predictive value. BJOG 2005; 112:977-80. [PMID: 15958003 DOI: 10.1111/j.1471-0528.2005.00612.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether oestradiol or follicle-stimulating hormone (FSH) measured prior to treatment could improve the predictive value of the risk score used to determine treatment in cases of persistent gestational trophoblastic disease (GTD). DESIGN Prospective observational study. SETTING Tertiary referral centre for GTD. POPULATION All women referred to Weston Park Hospital, Sheffield, with GTD between 1st January 1996 and 31st December 2000. METHODS Blood was taken prior to the initiation of treatment to measure oestradiol and FSH. The results were analysed with respect to the time taken for the beta-hCG to return to normal. MAIN OUTCOME MEASURES Time taken to reach a normal beta-hCG. RESULTS Data on 118 women were collected. Three women died of GTD during follow up. Using Cox's proportional hazards regression analysis, division of the risk scores into high and low risk groups (</=7, >7) demonstrated a significant difference with regard to the length of time taken to reach a normal beta-hCG level (hazard ratio 0.32; 95% CI: 0.18, 0.57) comparing high risk relative to low risk. However, addition of neither oestradiol nor FSH to the Cox regression analysis produced a significant hazard ratio (Ln oestradiol, 0.95; FSH 0.99). Division of the patients' risk scores into three groups of low (0-4), intermediate (5-7) and high (>7) risk groups produced similar results. CONCLUSIONS The measurement of neither oestradiol nor FSH appears to improve the prediction of outcome in persistent GTD when added to the risk score.
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Affiliation(s)
- Robert Macdonald
- Department of Gynaecological Oncology, Liverpool Women's Hospital, Liverpool, UK
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16
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Altieri A, Franceschi S, Ferlay J, Smith J, La Vecchia C. Epidemiology and aetiology of gestational trophoblastic diseases. Lancet Oncol 2003; 4:670-8. [PMID: 14602247 DOI: 10.1016/s1470-2045(03)01245-2] [Citation(s) in RCA: 243] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gestational trophoblastic diseases (GTD) consist of a group of neoplastic disorders arising from placental trophoblastic tissue after normal or abnormal fertilisation. The WHO classification of GTD includes hydatidiform mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour, and miscellaneous and unclassified trophoblastic lesions. GTD have a varying potential for local invasion and metastases and they generally respond to chemotherapy. Broad variations in the distribution of GTD exist worldwide, with higher frequencies in some parts of Asia, the Middle East and Africa, but the extent to which they can be attributed to methodological difficulties in obtaining accurate rates is unclear. Maternal age and a history of GTD have been established as strong risk factors for hydatidiform mole and choriocarcinoma. We review published data on the worldwide distribution of GTD, original data from cancer- registry-based statistics on choriocarcinoma, and major aetiological hypotheses, including parental age, AB0 blood groups, history of GTD, reproductive factors, oral contraceptive use, and other environmental factors.
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Affiliation(s)
- Andrea Altieri
- Laboratory of Epidemiology at the Mario Negri Institute of Pharmacological Research, Milan, Italy.
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17
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Abstract
Fertility and gynaecological malignancies have an important relationship. A clear inverse relationship exists between family size and the incidence of ovarian and endometrial cancer. Current methods of fertility control have an influence on subsequent development of various gynaecological malignancies. A slightly increased risk of breast cancer has been reported in current users and those who had used hormonal contraceptives (OCs) within 10 years; this risk declined with time and disappeared after 10 years. Women who started OC before age 20 had a higher relative risk; the disease did not spread beyond the breast in the majority. Most studies found OC to reduce the risk of ovarian and endometrial cancer. The relative risks of squamous cell carcinoma and adenomatous carcinoma of the cervix have been reported to be 1.3 and 1.5, respectively in ever-users of OCs; however, the aetiology of cervical cancer is multifactoral. Several reports suggest the beneficial effect of tubal ligation and breast feeding in reducing the risk of ovarian cancer. Therapy of gynaecological malignancies may have an influence on subsequent fertility. Amenorrhoea developing after treatment of hydatidiform mole may be due to choriocarcinoma, recurrent mole or a normal pregnancy. Choriocarcinoma can also develop after a partial mole. The risk of fetal teratogenicity from chemotherapy is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTD including cerebral metastases. In the young patient with gynaecological malignancy preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian epithelial cancers and even in advanced germ cell tumours. Recently, the fertility-sparing surgery of radical trachelectomy and pelvic lymphadenectomy has been carried out for early invasive cervical cancer in young women. Gynaecological cancer occurring in pregnancy is uncommon; it presents the clinician with a difficult situation to manage. In most instances the cancer is treated as though the patient is not pregnant; the timing and mode of delivery needs individualization. The overall prognosis for breast cancer complicating pregnancy is poor. Survival in cervical cancers diagnosed antepartum is similar to the non-pregnant patient. Ovarian cancer in pregnancy has a good prognosis because of the early stage at diagnosis.
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Affiliation(s)
- V Sivanesaratnam
- Department of Obstetrics and Gynaecology, University of Malaya, Kuala Lumpur, Malaysia
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18
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Nada W, Parker J, Carter J. Choriocarcinoma developing after prolonged molar surveillance. Aust N Z J Obstet Gynaecol 1999; 39:490-2. [PMID: 10687772 DOI: 10.1111/j.1479-828x.1999.tb03141.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- W Nada
- Sydney Gynaecologic Oncology Group, Liverpool Hospital, New South Wales, Australia
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19
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Trophoblastic diseases, treatment and follow-up investigations of the diseases in Hungary. Placenta 1999. [DOI: 10.1016/s0143-4004(99)80016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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20
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Affiliation(s)
- P M Fisher
- YCRC Department of Clinical Oncology, Weston Park Hospital, Sheffield, U.K
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21
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Affiliation(s)
- R S Berkowitz
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Boston, MA 02115, USA
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22
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Kenemans P. Gestational trophoblastic disease: management, the European way. Eur J Obstet Gynecol Reprod Biol 1994; 55:49-50. [PMID: 7958142 DOI: 10.1016/0028-2243(94)90202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- P Kenemans
- Free University Hospital, Department of Obstetrics and Gynaecology, Free University Amsterdam, The Netherlands
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23
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Newlands ES, Fisher RA, Searle F. The immune system in disease: gestational trophoblastic tumours. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1992; 6:519-39. [PMID: 1332835 DOI: 10.1016/s0950-3552(05)80009-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Trophoblastic tumours form a spectrum of disease from the borderline malignancy of HM to highly aggressive choriocarcinoma. Their management requires the integration of the information derived from serial hCG estimations, the clinical history and pattern of spread of the disease, so that our understanding of the prognostic variables can be applied appropriately. This maximizes the patient's chances of complete remission from her disease with the minimum of toxicity. Given our knowledge of this group of diseases and an integrated approach to management, it should be uncommon for any woman to die from her trophoblastic tumour.
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Affiliation(s)
- E S Newlands
- Department of Medical Oncology, Charing Cross Hospital, London, UK
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24
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Brinton LA, Wu BZ, Wang W, Ershow AG, Song HZ, Li JY, Bracken MB, Blot WJ. Gestational trophoblastic disease: a case-control study from the People's Republic of China. Am J Obstet Gynecol 1989; 161:121-7. [PMID: 2546427 DOI: 10.1016/0002-9378(89)90248-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A case-control study involving 331 patients with complete hydatidiform mole and 662 community controls matched to the cases on age and timing of pregnancy was conducted in Beijing, China. A history of a term birth was associated with reduced risk (odds ratio = 0.6, 95% confidence interval 0.4 to 0.9), with some evidence of further decrease with multiple births. Previous spontaneous abortions were not related to risk, although those with a prior induced abortion were at elevated risk, particularly if two or more abortions were involved (odds ratio = 2.8, 95% confidence interval 1.4 to 5.7). A history of having sought medical advice for infertility was associated with reduced risk (odds ratio = 0.5, 95% confidence interval 0.2 to 0.8), but those who reported use of herbal medicines during a first trimester of a previous pregnancy were at excess risk (odds ratio = 2.2, 95% confidence interval 1.3 to 3.6). In addition, a statistically significant trend in risk was observed with years of oral contraceptive use (odds ratio = 2.6, 95% confidence interval 0.9 to 6.9 for greater than or equal to 4 years of use). Dietary habits and family histories of cancer or trophoblastic disease were not related to risk in this study.
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Affiliation(s)
- L A Brinton
- Environmental Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892
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25
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Curry SL, Schlaerth JB, Kohorn EI, Boyce JB, Gore H, Twiggs LB, Blessing JA. Hormonal contraception and trophoblastic sequelae after hydatidiform mole (a Gynecologic Oncology Group Study). Am J Obstet Gynecol 1989; 160:805-9; discussion 809-11. [PMID: 2540654 DOI: 10.1016/0002-9378(89)90295-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A prospective randomized study was undertaken to determine whether the administration of oral contraceptives after the evacuation of a hydatidiform mole affects the human chorionic gonadotropin serum level in a way that leads to an increased frequency in the diagnosis of postmolar trophoblastic disease. Between 1981 and 1988, 266 patients were randomly assigned to either oral contraceptives or barrier contraception after evacuation of a hydatidiform mole. Patients were followed up until serum levels of human chorionic gonadotropin were normal or until specific criteria for the diagnosis of postmolar trophoblastic disease were met. Twenty-three percent of patients receiving oral contraceptives had postmolar trophoblastic disease, whereas those using a barrier method had a rate of 33%. The median time to spontaneous regression in the oral contraceptives group was 9 weeks, whereas the median time to regression in the barrier group was 10 weeks. Twice as many patients in the barrier group became pregnant in the immediate follow-up period. We conclude that oral contraceptives are the preferred method of contraception after evacuation of a hydatidiform mole.
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Affiliation(s)
- S L Curry
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts
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26
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Vessey M. Oral contraception and cancer. Contraception 1989. [DOI: 10.1016/b978-0-407-01720-7.50008-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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27
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Berkowitz RS, Goldstein DP. Diagnosis and Management of the Primary Hydatidiform Mole. Obstet Gynecol Clin North Am 1988. [DOI: 10.1016/s0889-8545(21)00122-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Dorreen MS, Pennington GW, Millar DR, Hill AS, Neal FE. Results of low-dose methotrexate treatment of persistent gestational trophoblastic disease in Sheffield 1980-1987. Acta Oncol 1988; 27:551-6. [PMID: 2849467 DOI: 10.3109/02841868809093587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Between January 1980 and October 1987, 115 evaluable patients were treated in Sheffield for persistent gestational trophoblastic disease (GTD) with a low dose methotrexate regimen (LD-MTX). Each course comprised MTX 50 mg given by i.m. injection for 4 doses on alternate days. Courses were repeated every 2 weeks and serum beta-hCG was used to monitor response. Overall, 80/115 (70%) of patients attained durable complete remissions (CR). Twenty-nine patients received the 'AVC' salvage combination of actinomycin-D 0.5 mg i.v. for 5 days, sequenced with cyclophosphamide 500 mg i.v. and vincristine 1 mg i.v., both given for 3 doses on alternate days. Sixteen (55%) patients attained a durable CR but 11 (38%) required further measures, 7 ultimately requiring hysterectomy. Two (7%) died during treatment. With 4 deaths overall (3 from metastatic GTD and 1 from infarction of the bowel), actuarial survival is 94% at over 7.5 years. A new Charing Cross prognostic scale weighted especially for hCG levels, number and sites of metastases, interval between pregnancy and start of treatment (score 0-6 each factor), was applied retrospectively to obtain a total score for each patient. Thus, 21/26 (81%) patients who scored greater than 8, required additional treatment after LD-MTX, compared with 18/89 (20%) of lower scoring patients (p less than 0.001). Because of the frequent morbidity associated with prolonged chemotherapy as well as the development of drug-resistant GTD, it is concluded that the 'high-risk' patients should receive more intensive combination chemotherapy at the outset.
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Affiliation(s)
- M S Dorreen
- Royal Hallamshire Hospital, Jessop Hospital for Women, Sheffield, England
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29
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Isidro-Gutierrez RF, Palo-Garcoa F, Blanco-Capito LR. Hydatidiform mole: patient profile and the impact of prophylactic chemotherapy at the Philippine General Hospital, 1975-1983. ASIA-OCEANIA JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1987; 13:175-81. [PMID: 3632465 DOI: 10.1111/j.1447-0756.1987.tb00246.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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31
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Affiliation(s)
- R L Prentice
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington 98104
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32
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Epidemiology of Gestational Trophoblastic Diseases. CLINICAL PERSPECTIVES IN OBSTETRICS AND GYNECOLOGY 1987. [DOI: 10.1007/978-1-4612-4698-5_2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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33
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Goldstein DP, Berkowitz RS. Single-Agent Chemotherapy. CLINICAL PERSPECTIVES IN OBSTETRICS AND GYNECOLOGY 1987. [DOI: 10.1007/978-1-4612-4698-5_13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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34
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35
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Newlands ES, Bagshawe KD, Begent RH, Rustin GJ, Holden L, Dent J. Developments in chemotherapy for medium- and high-risk patients with gestational trophoblastic tumours (1979-1984). BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1986; 93:63-9. [PMID: 3002420 DOI: 10.1111/j.1471-0528.1986.tb07815.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Identification of various prognostic factors at the start of chemotherapy allows patients with gestational trophoblastic tumours to be categorized into low-, medium- and high-risk groups so that they can be given the minimum treatment necessary to eliminate their disease. Most patients in the low-risk category can be treated with minimal toxicity using a methotrexate/folinic acid regimen and these patients are not considered in this report. Before 1979 patients in the medium-risk category were treated with a sequence of drugs which included, hydroxyurea, methotrexate, 6-mercaptopurine, actinomycin D, vincristine and cyclophosphamide. Since 1979 etoposide has been substituted for vincristine and cyclophosphamide. The 76 patients treated between 1979 and 1983 are all alive and in remission 1.1.85. Three patients (4%) relapsed and required retreatment and all are in remission. Fifty-six patients in the high-risk group, most at risk of developing drug resistance, were treated with a regimen incorporating etoposide with methotrexate, actinomycin D (EMA) and vincristine and cyclophosphamide (CO). EMA and CO were given on alternate weeks, resulting in an overall survival rate of 84%. Patients who had received prior chemotherapy had a survival rate of 74% and a relapse rate of 19% compared with 93% survival and 3% relapse rate in those who had not received prior chemotherapy. Toxicity with the EMA/CO regimen was significantly less than with an earlier regimen (CHAMOCA) used in the high-risk group.
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36
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Morrow P, Nakamura R, Schlaerth J, Gaddis O, Eddy G. The influence of oral contraceptives on the postmolar human chorionic gonadotropin regression curve. Am J Obstet Gynecol 1985; 151:906-14. [PMID: 2580438 DOI: 10.1016/0002-9378(85)90669-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This article reports a retrospective analysis of 149 evaluable cases of molar pregnancy managed at Women's Hospital, Los Angeles County/University of Southern California Medical Center, from January 1977, through June, 1983. In the 84 cases prior to 1981, the patients received estrogen-progestogen oral contraceptives after evacuation while the 55 patients seen after that used nonhormonal contraceptives. The frequency of abnormal regression of the serum beta-subunit of human chorionic gonadotropin in the two groups was not significantly different (22.6% in the hormonal contraception group versus 34.5% in the nonhormonal contraception group). The groups were compared for known and potential risk factors and were nearly identical with respect to patient age, parity, maternal blood type, and race. There were also no significant differences with respect to uterine size, preevacuation beta-subunit of human chorionic gonadotropin serum titer greater than 100,000 mIU/ml, and frequency of theca-lutein cysts. Gestational age was significantly shorter and the frequency of cases with a preevacuation beta-subunit of human chorionic gonadotropin serum titer greater than 250,000 mIU/ml significantly higher in the nonhormonal contraception group, indicating that the nonhormonal contraception group had a higher risk for abnormal human chorionic gonadotropin regression than the hormonal contraception group. We conclude that this study provides no evidence that the use of estrogen-progestogen oral contraceptives prior to human chorionic gonadotropin remission increases the risk for invasive mole or choriocarcinoma following molar pregnancy.
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Cox NH, Dufton PA. Treatment of Raynaud's phenomenon with ketanserin. BRITISH MEDICAL JOURNAL 1984; 289:1078-9. [PMID: 6435782 PMCID: PMC1443064 DOI: 10.1136/bmj.289.6451.1078-c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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38
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Drury M. Blood pressure follow up with nurse practitioner assessment and microprocessor based data retrieval. West J Med 1984. [DOI: 10.1136/bmj.289.6451.1079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Diggory RT, Simkin EP. Treating fissure in ano in outpatients: what dose of local anesthetic? BMJ : BRITISH MEDICAL JOURNAL 1984; 289:1079. [PMID: 6435784 PMCID: PMC1443037 DOI: 10.1136/bmj.289.6451.1079-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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40
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Guillebaud J. Are there any absolute medical contraindications to the progestogen only oral contraceptive? BRITISH MEDICAL JOURNAL 1984; 289:1079. [PMID: 6435783 PMCID: PMC1443004 DOI: 10.1136/bmj.289.6451.1079-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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41
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Jensen SL, Lund F, Nielsen OV, Tange G. Treating fissure in ano in outpatients: what dose of local anaesthetic? West J Med 1984. [DOI: 10.1136/bmj.289.6451.1079-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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42
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Skinner AC. Treating fissure in ano in outpatients: what dose of local anaesthetic? West J Med 1984. [DOI: 10.1136/bmj.289.6451.1079-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lähteenmäki P, Toivonen J, Lähteenmäki PL. Postabortal contraception with norethisterone enanthate injections. Contraception 1983; 27:553-62. [PMID: 6413130 DOI: 10.1016/0010-7824(83)90020-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Intramuscular injection of 200 mg norethisterone enanthate (NET-EN) was given to five women on the day of first trimester abortion. The injection was repeated twice at eight-week intervals, and thereafter at twelve-week intervals for one year. Plasma samples were collected for FSH, LH/hCG, estradiol, progesterone and norethisterone (NET) determinations. NET-EN did not affect the elimination of hCG, estradiol or progesterone. Plasma NET concentrations reached a peak (5.5-11 ng/ml) in about ten days after the injection and declined constantly thereafter, to levels of 0.18-0.64 ng/ml at 8 weeks after the injection. NET-EN postponed the increase in FSH secretion until 17-20 days after the injection, i.e. until plasma NET concentrations fell below 3 ng/ml. In three out of five women some follicular activity was present 5 weeks after NET-EN injection as evidenced by increased plasma estradiol concentrations. No ovulation occurred within 8 weeks after NET-EN injection, as judged by low progesterone values. There was a definite accumulation of NET during the first six months, when NET-EN injections were given at eight-week intervals. Mean plasma NET concentrations increased from 0.34 ng/ml at eight weeks to 0.78 ng/ml at 24 weeks. When the injection interval was increased to twelve weeks, the plasma NET concentrations prior to the next injection started to decrease. This was accompanied by increased follicular activity, culminating with one ovulation observed. It is concluded that in this population of women, an injection interval of less than twelve weeks is needed for ovulation inhibition.
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Ho Yuen B, Burch P. Relationship of oral contraceptives and the intrauterine contraceptive devices to the regression of concentrations of the beta subunit of human chorionic gonadotropin and invasive complications after molar pregnancy. Am J Obstet Gynecol 1983; 145:214-7. [PMID: 6849356 DOI: 10.1016/0002-9378(83)90494-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
One hundred ninety-four patients with pathologically confirmed molar pregnancy and intact uteri were studied prospectively. Group A included 177 patients in whom the beta subunit of human chorionic gonadotropin (hCG-beta) declined to normal (less than 5 mlU/ml) without chemotherapy, whereas group B included 17 patients with invasive complications in the postmolar phase which necessitated the use of chemotherapy. Only women with intact uteri were included in the study. In group A, there were no significant differences in the human chorionic gonadotropin (hCG) positive interval between women who used intrauterine contraceptive devices, barrier and other methods, and those who used oral contraceptives. Differences in the proportions of women in groups A and B who used the oral contraceptives and intrauterine contraceptive devices were not observed. However, the mean dosage of estrogen and the proportion of women who ingested more than 50 micrograms of estrogen were higher in group B. These data suggest that (1) the oral contraceptives with less than 50 micrograms of estrogen and the intrauterine contraceptive devices do not prolong the hCG-beta positive interval nor increase the risk of invasive complications in the postmolar phase which requires the use of chemotherapy; and (2) the dose of estrogen (in formulations that contain more than 50 micrograms) rather than the oral contraceptives per se may influence the risk of these postmolar complications.
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Abstract
This review was undertaken to record recent progress in understanding and management of this unusual, relatively rare, but potentially fatal disease of trophoblast in the fetal allograft. The generic term "gestational trophoblastic neoplasia" has been introduced to represent the broad spectrum of clinical behaviour. The cytogenetic origin is interestingly diverse and the chromosomal karyotype of the tumour is varied, depending upon the type of antecedent pregnancy. The major contribution to progress in the last decade has come from the accumulation of experience by tumour registries and referral centres. Data from studies of biochemical markers, especially of hCG-beta and more recently, SP1, and their accurate measurement have led to the development of a sensitive method of monitoring the disease during follow-up and treatment. Diagnosis is enhanced by ultrasound examination and treatment by suction aspiration is generally regarded as the safest mode of molar evacuation. Although prophylactic chemotherapy has resulted in reduction in incidence of persistent disease (especially in the "high risk" patient), an alternative and, perhaps more rational method, is close follow-up by hCG-beta levels. A better understanding of the use of chemotherapy and the success in achieving the objectives of early treatment when tumour load is small, and selection of the most effective regimen, on the basis of matching type of treatment to the likelihood of drug response (or resistance), are now extended to consideration of treatment for the resistant tumour or tumour in less accessible sites, such as in the brain. With these advances, reproductive function can safely be preserved in the younger patient, unnecessary drug toxicity avoided, mortality reduced considerably and long-term sequelae of chemotherapy kept at an insignificant level.U
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48
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50
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Gal D, Simpson ER, Porter JC, MacDonald PC, Buchsbaum HJ. Failure of contraceptive steroids to modify human chorionic gonadotrophin secretion by hydatidiform mole tissue and choriocarcinoma cells in culture. Steroids 1981; 37:663-71. [PMID: 7027540 DOI: 10.1016/s0039-128x(81)90197-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The effect of steroids contained in oral contraceptives, namely ethinylestradiol:17 alpha-ethinyl-1,3,5,(10)-estratriene-3, 17-diol (E) and norethindrone acetate:17 beta-acetoxy-17-ethinyl-4-estren-3-one (N), on cell replication and human chorionic gonadotropin (hCG) secretion by choriocarcinoma cells in monolayer culture and by hydatidiform mole tissue maintained in organ culture were studied. The steroids were added to the culture medium individually or in combination to achieve a range of concentrations (10-10 to 10-4), within and beyond the presumed concentration of these substances in the blood of women taking oral contraceptives. The effect of luteinizing hormone releasing hormone (LHRH) on hCG secretion by choriocarcinoma cells in monolayer culture also was investigated. The rate of hCG production by either choriocarcinoma cells in monolayer culture or by hydatidiform mole tissue maintained in organ culture was not affected by the hormones used in this study; indeed hCG secretion remained reasonably unchanged even with high concentrations of steroids (up to 10-4 M) or LHRH (up to 10-4 mg x ml-1). Cell replication, as measured by increase in amount of cellular protein and DNA, was not stimulated by either of these compounds.
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