The aim of the fertility work-up is to exclude recognised causes of infertility and to distinguish those couples who have good spontaneous pregnancy prospects from those who have poor prospects. Information gathered by medical history, clinical findings and results of the diagnostic tests should help the clinician in counselling subfertile couples. The initial diagnostic tests for infertility should include a basal body temperature chart or midluteal phase progesterone level, a semen analysis and a test for tubal patency. Ovarian reserve tests can be used in selected cases. More research is needed in the predictive value of the outcome of diagnostic tests in reproductive medicine.
The etiology of endometriosis remains unclear and at the moment most of the therapeutic options are directed towards the relief of symptoms. In this context, in vitro fertilisation (IVF) overcomes anatomical distortion but our ability to influence environmental factors still seems to be limited. The improvement in pregnancy rates in endometriosis associated infertility is as important as the reduction in complications, and a careful analysis for the indications of each treatment option should be guaranteed. The use of gonadotropin releasing hormone agonists (GnRHa) for 3–6 months has shown to improve IVF outcomes, while increasing literature questions the role of surgery prior to the start of an IVF treatment cycle in views of fertility improvement. Early referral of these women to specialised centres is advised.
Pelvic inflammatory disease and pelvic abscesses have been reported as a major complication following a wide variety of obstetrical, gynaecological and surgical procedures. The aim of this review article is to emphasize the need for a more aggressive approach to detect and to treat what can be a debilitating condition that if inadequately treated may result in mortality. The large numbers of options available are discussed under the headings of: conservative management, interventional radiological management and surgical treatment. Lastly, preventive strategies are discussed, as pelvic inflammatory disease may result in tubal factor infertility, ectopic pregnancies, chronic pelvic pain and tubo-ovarian/pelvic abscesses.
Fetal growth restriction (FGR) is a common clinical problem that has a significant effect on perinatal morbidity and mortality. In addition, it also adversely influences adult health, as it increases the risk of cardiovascular disease and impaired glucose tolerance. There is growing evidence that genes play a role in the pathogenesis. Karyotypic abnormalities, affecting both the fetus and the placenta, are known to be associated with fetal growth restriction. This not only impacts on clinical management but has also aided the understanding of the mechanisms controlling fetal growth. In particular, there is an increasing appreciation of the role of imprinted genes in growth and development. There is good genetic epidemiological evidence that genes also play a role in the more common, multifactorial fetal growth restriction, seen in the presence of a normal karyotype. The number of candidate genes studies is increasing and includes members of the renin angiotensin system and the insulin-like growth factor axis. The most extensively investigated to date are the inherited thrombophilias and meta-analyses seem to support an association with fetal growth restriction. However, larger studies are urgently required to confirm this association. There is currently no evidence to support screening low-risk pregnant women for inherited thrombophilias, and there are no randomised controlled trials to suggest that treatment with anticoagulants improve outcome. At present screening or treatment should occur only within such trials.
Ovarian hyperstimulation syndrome is a serious and potentially life-threatening complication of infertility treatment. The symptoms are generally triggered by human chorionic gonadotrophin (hCG) following ovulation induction in an in vitro fertilisation cycle. It is believed that the underlying pathology is a shift of protein-rich fluid from the intravascular space to extravascular compartments. The exact aetiology has not been established however it is felt that vascular permeability plays a key role which may be mediated by the immune system, VEGF and the ovarian rennin–angiotensin system. Prevention of the syndrome is important and involves monitoring of patients undergoing ovulation induction, modifying treatment regimens and pharmacological interventions. The management of patients depends upon the severity of the condition. There should be a low threshold for hospital admission where close monitoring, replacement of intravascular volume, thromboprophylaxis and paracentesis (if required) can be effected.
The placenta is actively involved in transporting nutrients to the fetus, it has both direct and indirect effects on fetal cardiovascular function and has endocrine influences on the mother and fetus. As such, a properly functioning placenta is crucial for normal fetal development and plays a central role in mediating effects of the maternal environment on the fetus. An altered external environment or abnormal placental function can induce developmental changes in the fetus and may have important consequences for the risk of cardiovascular and metabolic disease in adult life.
Obstetricians frequently need to decide whether to induce a woman who has previously been delivered by Caesarean section (LSCS). There is very little evidence from randomised controlled trials to aid their decision making. Observational studies, with their inherent flaws, suggest a 3.6% maternal complication rate in women undergoing repeat elective LSCS, and approximately 66% vaginal delivery rate and 1% uterine rupture rate in women who were induced. There is little evidence to guide the choice of induction agent. Various factors have been suggested to predict a successful vaginal delivery, but a previous vaginal delivery appears to be strongly predictive of a good outcome. Alternative strategies, such as stretching and sweeping the membranes or awaiting spontaneous labour, may reduce the need for induction. If labour is induced in a woman with a scarred uterus we should ensure that the high risk situation is not compounded by poor care in labour.
Accurate diagnosis is important to ensure optimal management of dysmenorrhoea—for women whose dysmenorrhoea does not respond to first line treatments, diagnostic laparoscopy is often useful. Randomised trials have confirmed the effectiveness of a wide and varied array of treatments: conservative approaches including aerobic exercise, topical heat, relaxation therapy, high frequency transcutaneous electrical nerve stimulation (TENS) and timely diagnostic ultrasound; drug treatments including paracetamol and non-steroidal anti-inflammatory drugs, hormonal drug treatments for endometriosis, progestogen drug treatment for unexplained chronic pelvic pain; alternative and newer drug treatments including Vitamin B1, Vitamin E, magnesium, fish oil, toki-shakuyaku-san; surgical treatments including laparoscopic excision and laparoscopic ablation for endometriosis, laparoscopic ovarian cystectomy for endometriomas, the levonorgestrel intrauterine system as a post-operative adjunct for endometriosis, and laparoscopic uterine nerve ablation for primary dysmenorrhoea. The future research agenda has been defined by gaps in randomised trial evidence where data are insufficient or conflicting.
It is well established that there is a strong relationship between fetal growth and the subsequent development of type 2 diabetes and other features of the metabolic syndrome. The importance of the fetal environment has been shown in both human and rodent studies. Twin studies suggest that the relationship can be independent of genotype, and studies of individuals in gestation during famine clearly indicate the importance of the fetal environment. However the mechanistic basis of the relationship is as yet unknown. To investigate the underlying mechanisms behind this relationship, a number of animal models have been developed. Nutritional insults administered maternally such as calorie restriction, iron restriction, high fat feeding and protein restriction have all been shown to lead to features of the metabolic syndrome in the offspring. Exposure to hormones, surgical interventions and gestational diabetes have also been shown to have detrimental effects on the offspring. These animal models provide strong evidence that alterations in the fetal environment can lead to metabolic diseases in adult life.
Gynaecologists are frequently referred women with chronic pelvic pain. These women are often frustrated as they seek to understand their pain and how to manage it. The investigation of women with chronic pelvic pain hinges on taking a full history including social and psychological issues and usually involves laparoscopy and transvaginal ultrasound. Management is often complex and includes taking a multidisciplinary approach as well as using hormonal agents, surgery and psychological interventions.
Until recently, the treatment of choice for Stage 1A cervical cancer has been simple or radical hysterectomy. With excellent survival rates and an increasing desire to conserve fertility, conservative surgical methods are being used. The object of this review is to discuss prognostic factors, treatment options and methods of follow-up for women with microinvasive cervical cancer.
Female hirsutism is a distressing and embarrassing problem although there is rarely a sinister underlying pathology. It is characterised by excessive coarse terminal hairs in a male-like pattern and is due to increased androgen production or increased sensitivity of androgen receptors. Polycystic ovary syndrome (PCOS) is by far the commonest cause of hirsutism. A systematic evaluation of the patient will readily identify any serious underlying cause. Therapeutic options often include a combination of medical treatments targeting different sites of action, apart from mechanical ablation, cosmetic measures, or use of a new topical treatment to reduce the rate of hair growth. The combined oral contraceptive pill (OCP) is the most commonly used treatment and can supplement other medications but may not be ideal for obese patients. Finasteride and cyproterone acetate are effective treatments and new evidence suggests that low doses of these treatments can be just as effective. Spironolactone can be an effective treatment for hirsutism, although it is not as widely used in the UK as it is elsewhere in the world. Insulin sensitisers, particularly metformin, are being used increasingly with very promising results but more data are needed. Obesity can aggravate hirsutism and influence the choice of treatment. Weight reduction should be a crucial element of treatment in women who are overweight. Due to the long growth cycles of body hair, any objective benefit from a systemic treatment would not be expected before 6–12 months. Concomitant reliable contraception should be used to avoid the possible harm of antiandrogens on a male foetus. Vaniqa and Dianette are the only licensed treatments for hirsutism in the UK.
Laparoscopy entered the field of gynaecology in the mid-1950s, but the technique was slow to evolve until the beginning of the 1990s, when it became more widely applied in gynecological oncology. Although few trials have looked at the safety of laparoscopy in oncology, it is now widely used for most gynaecological malignancies. Cervical cancer has probably the strongest literature devoted to it, and so far this does not seem to demonstrate a detrimental survival profile. Uterine cancer relies on laparoscopy for the initial surgery or staging of an unstaged patient. In ovarian cancer, the technique is mostly used in early cases for staging purposes, or in advanced cases before neoadjuvant chemotherapy. Trocar metastasis is probably not as frequent as initially suggested, but good surgical technique is of paramount importance in preventing this. Although laparoscopy is very promising and probably oncologically safe, and although there are few published prospective trials, the technique demands satisfactory additional training and, in the setting of gynaecological cancers, should be reserved for trained subspecialists.
Cervical incompetence is an important factor in the aetiology of preterm birth and mid-trimester miscarriage. Its diagnosis usually relies on clinical history, but recent studies have investigated the role of transvaginal ultrasound scanning, with the finding of shortened cervical length being associated with an increased risk of preterm delivery.
Although outcomes in women's health are not as spectacular as in conditions like cancer, the large number of women who present each year means that the overall impact of these conditions is enormous. Similarly, although suboptimal therapies may not individually be much worse than best practice, the overall effect on a nation's health, wealth and happiness is substantial. There is a therefore a real need to gather evidence as to which, if any, women, benefit from any particular therapy. Well-designed randomised controlled trials (RCTs) help provide reliable evidence on a treatment's effectiveness. In this article, we consider important aspects of designing a good clinical trial; and in particular their application to women's health issues. Designed as an overview of the subject, we consider how large trials need to be; the choice of endpoints; how they should be analysed; and also more practical considerations in running a successful trial. The considerations given here are of use not only to clinicians or researchers preparing to run their own trial, but also to anyone who reads reports of trials, and should help clinicians make informed judgements about evidence presented in published reports.
Approximately 10% of cancer deaths in women in Westernised countries are due to gynaecological malignancy. Cancer results from the accumulation of multiple genetic alterations. Some alterations occur in the germline and increase susceptibility to disease during an individual's lifetime. Such alterations often manifest themselves as a clustering of cancer cases within families. However, these are relatively rare. Most genetic changes are spontaneous, occurring in somatic cells, and are associated with a progressive tumour development. It is likely that the compliment of genetic changes that initiate and accumulate during tumour formation influence clinical features of disease including histopathological subtypes, response to therapy and, ultimately, patient survival. It is hoped that a greater understanding of the underlying genetic basis of tumourgenesis will lead to better risk prediction for individuals with susceptibility to cancer, an improved ability to detect cancer at an earlier, more treatable stage and to the identification of novel therapeutic targets. Many of these goals are dependent on the continuing progress of biotechnology to develop high throughput methods for the rapid analysis and characterisation of blood and tumour tissue specimens for implementation in routine clinical diagnostic procedures.
After an introduction recounting the pronatalist views of the world's religions, the article goes on to explore each of the major religions, Judaism, Christianity, Islam, Hinduism, Sikhism and Buddhism and their belief systems in relation to contraception and abortion. This is followed by a discussion of the practical consequences of these beliefs and of the role of the professional in helping women and couples of the varied faiths in their choice of methods. How these choices may affect religious practices and vice versa is also considered.
Diabetes in pregnancy is associated with significant morbidity and mortality and its prevalence is rising. The management of this condition involves the co-ordinated care of a multi-disciplinary team consisting of endocrinologists, obstetricians, midwives and dieticians. This review concentrates on the control of diabetes in pregnancy, by which both maternal and fetal complications can be minimised. The management of gestational diabetes centres on self-monitoring of blood glucose, diet control and if necessary, insulin treatment. Women with gestational diabetes have a high risk of developing type 2 diabetes later in life and should be counselled on the importance of lifestyle modification. In patients with pre-existing type 1 and 2 diabetes, pre-conception counselling is important to optimise pregnancy outcome. Such counselling also provides an opportunity to screen for pre-existing vascular complications such as retinopathy (which may worsen during pregnancy) and measure baseline markers of glycaemic control such as HbA1C. Insulin requirements vary during pregnancy and hence daily assessment of blood glucose levels should be performed and the insulin dose adjusted accordingly. Conventional injections of insulin or insulin pumps are both effective in optimising glycaemic control, although the latter is generally used in patients for whom achieving normoglycaemia is challenging. Blood pressure should be regularly monitored and hypertension treated. The evidence for the efficacy of various treatment modalities has been examined in this review. By optimising diabetes management in pregnancy, it is hoped that the pregnant diabetic patient can look forward to a similar pregnancy outcome as that of a normal woman.
Pre-eclampsia (PE) and intra-uterine growth restriction (IUGR) cause significant maternal and perinatal morbidity and mortality. Placental dysfunction is central to the development of both conditions. Although the pathophysiology of these conditions is unknown, there is common placental pathology with an increase in apoptotic cell death seen within the trophoblast. In addition, in pre-eclampsia, apoptotic fragments of syncytiotrophoblast have been detected in the maternal circulation. Both hypoxia and reactive oxygen species have been proposed as potential mediators of the insults to the placenta in pre-eclampsia and IUGR resulting in apoptosis. Cell proliferation and apoptosis are tightly regulated by oncoproteins. The increased apoptosis observed within trophoblast is associated with an alteration in oncoprotein expression within placental tissue. Further investigation of these oncoproteins capable of detecting or responding to cell damage may improve understanding of the pathophysiology of pre-eclampsia and IUGR.
This review article aims to give a comprehensive insight into both the historical and current thoughts on all aspects of endometriosis including aetiology, diagnosis, and medical and surgical treatments. The prevalence of endometriosis is about 6–8%, and may affect up to two million women in the United Kingdom. It causes, through pain and infertility, a significant problem for sufferers, their families and society as a whole. There is no conclusive evidence to explain its aetiology although our understanding of the basic pathophysiology is improving. However, there remains a substantial lack of understanding in all areas of disease.
