Microwave endometrial ablation (MEA™) has evolved from a theoretical technology, through rigorous laboratory and clinical testing to become an effective treatment for heavy menstrual loss, with a sound evidence base. The purpose of this article is to review the scientific basis, clinical research, safety and clinical applications of this endometrial ablative technique.
Polycystic ovary syndrome (PCOS) is a heterogeneous condition that represents a continuous spectrum from asymptomatic women with polycystic ovaries demonstrated on ultrasound through to those with the classic features of infertility, obesity and hyperandrogenaemia. It is now generally believed to be a metabolic and endocrine condition secondary to relative insulin resistance and compensatory hyperinsulinaemia. Hyperinsulinaemia is thought to cause abnormal ovarian androgen metabolism and altered ovarian gonadotrophin response resulting in anovulation, oligoamenorrhoea and features of hyperandrogenism. Logically, therapeutic strategies aimed at correcting the insulin resistance (weight loss and insulin sensitisers) would in theory make more sense than symptom relief. The potential increased risks of cardiovascular disease and non-insulin-dependent diabetes mellitus would also be obviated. In practice, however, several gaps exist in our current knowledge of the pathophysiology of PCOS with resulting challenges in strategies that aim primarily to correct insulin resistance. This article discusses the current understanding and management of polycystic ovary syndrome. Novel future research directions are suggested.
Pelvic organ prolapse is a common problem significantly affecting women's quality of life, particularly in later years. Transperineal, two-dimensional ultrasonography can be used for the assessment of female pelvic floor dysfunction for pelvic organ morphology, tissue biomechanics and in vivo properties of prosthetic implants. The role of transperineal ultrasound for the assessment of pelvic organ prolapse is still developing, but with the rapid development of three- and four-dimensional technology may allow dynamic assessment of anatomy in the axial plane. Three-dimensional ultrasound also permits the storage of data volumes for analysis at a later stage, which introduces the ability to independently review images in any plane offline. Further evaluation and research of this imaging tool is required to identify its place in the assessment of women for pelvic organ prolapse and its role in surgical audit.
The possible link between ovulation-inducing agents and ovarian cancer has been the focus of considerable research effort over the past decade. Epidemiological studies addressing this issue have varied in their ability to achieve adequate sample sizes, obtain accurate measures of subfertility and fertility drug use, and eliminate potential bias due to confounding variables. Despite these methodological challenges, nulliparity has consistently been associated with increased rates of epithelial ovarian cancer. An additional modest effect of subfertility has been suggested by some studies, particularly among women who remain childless despite prolonged non-pharmacological attempts to conceive. Type of subfertility may also impact on ovarian cancer risk: ovulatory disorders, endometriosis and unexplained subfertility have all been associated with increased rates of the disease. However, most studies have shown no overall increased risk of epithelial ovarian cancer in women exposed to ovulation-inducing agents, irrespective of the type of fertility drugs used and duration of treatment. While results are generally reassuring, there is a clear need for larger studies employing longer periods of follow-up, detailing precisely the types, doses and duration of treatments patients have received, and controlling for potential confounding reproductive factors. While uncertainties persist, patients undergoing ovulation induction should be informed of the possible increased risk of ovarian cancer following treatment, but it should be emphasised that this risk is doubled at most. Short courses of ovulation induction are probably preferable but there is no evidence for post-treatment screening for ovarian cancer in these patients.
Menorrhagia is common, affecting 50% of the female population. It is becoming more apparent that haematological causes, many often under-diagnosed, may be responsible. With increasing laboratory sophistication, platelet functional defects, von Willebrand disease (vWD) and clotting factor deficiencies are diagnosed more frequently. Menorrhagia may be the first clinical manifestation of a bleeding disorder therefore timely diagnosis and management are essential especially if surgery is to be considered as a definitive treatment for menorrhagia not responding to medical management.
The standard form of surgical intervention in advanced ovarian cancer is to undertake a pelvic clearance, and remove all tumour. When the latter is not feasible, then a ‘debulking’ operation is performed. This is a procedure whereby the intra-abdominal tumour load is reduced to what is termed ‘optimum’ residual disease (which has varied definitions). Compared with other intra-abdominal solid tumours, this approach is unique to ovarian malignancies. Whilst many retrospective studies, and meta-analyses may indicate that patients with ‘optimum’ debulking survive longer than those with a greater amount of residual disease, the reality is that this surgical intervention has never been exposed to a randomised controlled trial. Therefore, rather than ‘optimum’ debulking enhancing survival, it could be that the ability to achieve the ‘optimum’ is only reflecting the inherent tumour biology of a more chemo-sensitive disease. This debate will continue until such studies are completed.
The standard surgical procedure for uterovaginal prolapse is vaginal hysterectomy and reconstruction of the uterosacral ligaments. Women who wish to have further children are generally advised to delay surgery until their family is complete. Some women may still wish to consider treatment before family completion if symptoms are severe and others may wish to conserve the uterus for personal reasons. In addition hysterectomy has specific risks, may be a causative factor in subsequent bladder symptoms and does not specifically cure the prolapse. A variety of other surgical procedures to conserve the uterus have been described and many show high rates of symptom improvement in the short term. Fertility after conservative surgery for prolapse is unknown as very few pregnancies have been reported in the literature after such surgery.
Locally advanced cancer of the uterine cervix covers a broad disease spectrum comprising primary tumours of >4cm in size or FIGO stage >IIA and all local tumour relapses except the rare cases of small recurrences in a retained cervix. Treatment designs have to consider the probability of pelvic and periaortic lymph node metastases and – albeit less frequent in primary disease – distant metastases.
Menorrhagia is a common clinical problem in routine gynaecological practice. Optimal methods for diagnostic work up and therapeutic interventions remain topics for ongoing debate. This can be explained in part by rapid advances in diagnostic and therapeutic technologies. However, the limited quality of available evidence due to inadequate study conception, design and conduct is responsible for much of this uncertainty. Future research should concentrate on a robust approach to the assessment of health technologies used in diagnosis and treatment, so that relevant studies capable of answering well-formulated research questions are designed. Outcomes of importance to patients, namely health related quality of life, should be used as primary outcome measures. Specific areas highlighted for research in this review include the role of particular diagnostic modalities, such as ultrasound and hysteroscopy, in terms of their ability to change patient outcome thorough primary research and decision-analytic modelling. The place of minimally invasive therapies and appropriate utilisation of the outpatient ‘ambulatory’ setting requires clarification through randomised controlled trials. Economic endpoints need to be assessed to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions.
The separate but complementary roles of follicle stimulating hormone (FSH) and luteinizing hormone (LH) in stimulating folliculogenesis and ovulation are well established. However, it is not known if there are levels under which low LH concentrations may be equally or suboptimal for oocyte quality and subsequent embryonic development competence. On the other hand, there are some conflicting data related to the high levels of LH promoting follicular atresia and early miscarriage. This has lead to the concept of a ‘therapeutic window’ of LH for successful conception in assisted reproductive technology (ART) and ovulation induction. In hypogonadotrophic hypogonadism (HH), rLH is effective for supporting FSH-induced follicular development, in a dose related manner and rLH promotes estradiol secretion, enhances the effect of FSH on follicular growth, and permits successful luteinization. Some patients with prolonged and profound down-regulation response like hypogonadotrophic hypogonadal patients and may benefit from concomitant exogenous administration of LH. Retrospective meta-analyses comparing LH-containing regimens with LH-free stimulations have provided conflicting results in normal ovulatory patients. Until recently, human menopausal gonadotrophin (HMG) preparations were the only source of exogenous LH, however, recombinant human luteinizing hormone (rLH) is now available for clinical use, providing a new treatment option. rLH is well characterized and production is tightly controlled resulting in a highly consistent product. In addition, it has been shown that rLH is as effective but safer than human chorionic gonadotrophin (hCG) in inducing final follicular maturation and ovulation.
Menorrhagia is a common complaint and accounts for 12% of referrals to gynaecology clinics. Prevalence increases with age and peaks just prior to menopause.
Abdominal myomectomy is the commonest conservative surgical procedure offered to patients with symptomatic fibroids and as a fertility enhancing procedure to some women with large intramural fibroids when no other cause for subfertility is evident. Historically myomectomy has been considered to be a complex procedure with high risk of complications. However, there is no evidence to support this assumption and recent studies have shown that the morbidity of myomectomy and hysterectomy is comparable. In recent times, new treatment strategies with a minimally invasive approach have evolved but are available only in selected centres and their efficacy has not been evaluated in the light of well-designed research trials. Therefore, myomectomy remains the mainstay of surgical treatment in women who wish to retain their uterus. This review aims to dispel the misconceptions about morbidity of myomectomy and provides an evidence-based account of the measures that can be taken to minimise it.
This review describes the development of the BSGE nurse hysteroscopy training programme over the past 4 years. The programme attracts academic credit and is often a way into the Masters education pathway. A recent survey of qualified nurse hysteroscopists illustrates how much hospitals rely on these individuals for teaching, training and provision of services. All nurse hysteroscopists are working in outpatient hysteroscopy clinics and new developments within the training programme mean that they can now offer treatment as well as diagnosis.
Inappropriate use of hormone replacement therapy (HRT) may increase the risk of endometrial cancer. Unopposed oestrogen is associated with the development of endometrial hyperplasia and if continued of endometrial cancer. The addition of progestogen for at least 12 days in each cycle will prevent hyperplasia in the short term but with use over 5 years there will still be an increased risk of endometrial disease. Long cycle therapy with a progestogen course every three months or more will reduce the frequency of bleeding, which will be popular, but protection of the endometrium is less certain.
Chronic pelvic pain (CPP) is a common problem with a prevalence of about 38/1000 among women aged 20–50 years. The main gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is irritable bowel syndrome and genitourinary diagnosis includes pathology such as interstitial cystitis. It is a challenge instigating the right investigations for patients with chronic pelvic pain because there is a considerable symptom overlap. They also have a higher prevalence for symptoms such as dysmenorrhea and dyspareunia. In this review, we aim to discuss the clinical consultation necessary to help us decide upon which investigative tools we need to use to help diagnose the cause(s) of CPP, although one needs to stress that a specific cause may not be found in patients with CPP and symptom focused multidisciplinary management of CPP is at least as important as diagnosis of specific pathology and disease focused treatment.
Menopause is associated with vasomotor symptoms, which can affect the quality of life of some women. Although oestrogen replacement therapy is an effective treatment yet many women declines its use especially with the highly publicised findings of Women Health Initiative trials. Although oestrogen withdrawal is the main cause of hot flushes, neurotransmitter modulators are involved in its pathophysiology. Selective serotonin reuptake inhibitors as venlafaxine, flouxetine and paroxetine have been shown to reduce hot flushes by nearly 60% and are generally well tolerated. Trials on gabapentin, another group of neurotransmitter modulators, yielded similar results. Clonidine is a central α-adrenergic agonist, which is only modestly effective in reducing hot flushes. Their side effects may preclude their use but may be a suitable option for hypertensive patients with hot flushes. Non-prescription medications are widely popular as natural alternatives to hormone replacement therapy despite the lack of enough data regarding their safety. The current available evidence suggests that phytoestrogens are ineffective in treating hot flushes. Trials of black cohosh lack methodological quality and yielded conflicting results. Other herbal medicines are only included in isolated trials. Systemic progestogens can be effective in treating hot flushes but their long-term effect in breast cancer survivors is uncertain. There is little evidence to support progesterone cream for treatment of vasomotor symptoms. Many women might benefit of life style modifications and regular physical exercise.
Endometriosis affects millions worldwide. Its symptoms include non-cyclical pelvic pain, dysmenorrhoea, dyspareunia and subfertility. The diagnosis is made by laparoscopy, and operative laparoscopic surgery for endometriosis is also possible. As well as conventional laparoscopic techniques, lasers have been used in laparoscopic surgery for the past two decades. The main advantages of lasers are that they allow surgeons to perform operative surgery via the minimally invasive approach of laparoscopy, the operation is largely bloodless, the injury to the surrounding tissue is highly controllable and postoperative adhesion formation has been shown to be no greater than with conventional methods. The CO2 laser is the most precise laser for the division of adhesions and the accurate and safe vapourization of deposits of endometriosis. Several types of operative procedure to treat endometriosis have been carried out with the CO2 laser laparoscope. This article provides an overview of laser physics, the effects on the tissues, the clinical use of lasers, the appearance of endometriotic lesions and the management of endometriosis of the peritoneum, ovary, rectovagina, ureter and bladder by laser laparoscopic techniques.
Vulvar intraepithelial neoplasia (VIN) is a precancerous skin disorder of the vulva. It is currently classified on the basis of histological findings as VIN1, −2, or −3. Clinically useful tumour markers do not yet exist. Up to 90% of cases of VIN3 are associated with human papillomavirus (HPV). Even with appropriate treatment, approximately 5% of women with VIN3 will develop cancer of the vulva, necessitating appropriate long-term follow-up. The two main aims of management of VIN are to prevent cancer and to resolve symptoms. Research into VIN has been limited by the rarity of the disease. Most data come from published case series focusing on VIN3.
This review addresses the effects of childbirth on the pelvic floor, urinary continence mechanisms and the perineum. Genitourinary prolapse affects 15% of women and stress incontinence 20–30%. The major risk factors are age and childbirth, with severity increasing with parity. There are three mechanisms of support for the pelvic organs and bladder neck. These are (i) the muscular component: levator ani and urethral sphincter with their intact nerve supply, (ii) the endopelvic fascial connections with the levator ani, and (iii) the posterior angulation of the vagina. Childbirth causes direct myogenic damage, dennervation and defects in the endopelvic fascia along with widening of the urogenital hiatus. Elective caesarean section without labour has in the past thought to be protective. More recent data suggests this effect to be less pronounced and antenatal stress incontinence appears the most important predictive factor for the development of postnatal stress incontinence. The targeting of pelvic floor exercises under direct supervision from a physiotherapist have shown a reduction in the development of short and long term stress urinary incontinence.
The physical features determining the sex of an individual are the karyotype, the internal and external sexual organs, the gonads and the secondary sexual characteristics which appear at puberty. Intersex conditions occur when there is a defect in the normal process of sexual maturation that results in abnormalities in any of these features. The management of these conditions is in the midst of great change. Every aspect is currently under review including diagnostic techniques, timing and nature of treatment including surgery, and information given to the patients. The true incidence of most of these conditions is unknown and great secrecy still surrounds them.
