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PubMed1999

Argument for the surgical staging of apparent early endometrial cancer.

Cancer of the uterine corpus, commonly referred to as cancer of the endometrium or cancer of the uterus, continues to be the most common pelvic genital malignancy affecting western women (1). In 1998 in the United States 36,100 women were diagnosed with this cancer, and there were 6,300 deaths from this condition in that year. Of concern is that despite a relatively stable incidence over the last decade, the annual number of deaths since 1987 from endometrial cancer has more than doubled (2). Many controversies exist in the management of apparent early endometrial cancer. These include: 1. The role of surgical staging which includes pelvic lymphadenectomy. 2. The role of the subspecialist gynaecological oncologist in primary surgical treatment. 3. Indications for vaginal and external beam radiotherapy. 4. Who is at risk for recurrence? 5. The role of laparoscopic approach to the management of this disease. Despite their importance, these and other issues have not been appropriately addressed by prospective randomized studies. Treatment strategies and algorithms have thus been based upon a combination of clinicopathological studies and uncontrolled reviews. The views expressed in this clinical opinion are those of the Sydney Gynaecologic Oncology Group and reflect our philosophy on the current management of this tumour, supported by recent and appropriate peer reviewed scientific literature.

Brachytherapy↗
PubMed1992

High levels of Gardnerella vaginalis detected with an oligonucleotide probe combined with elevated pH as a diagnostic indicator of bacterial vaginosis.

We have demonstrated a new approach to diagnosing bacterial vaginosis (BV) that is based on measuring the concentration of Gardnerella vaginalis in vaginal fluid with DNA probes. G. vaginalis is virtually always present at high concentrations in women who have BV but is also detected frequently in normal women, usually at concentrations of less than 10(7) CFU/ml of vaginal fluid. Elevated vaginal pH is another sensitive indicator of BV, although it can occur in conjunction with other conditions. We have proposed that quantitative measurements of G. vaginalis using specific DNA probes can serve as a useful aid in diagnosing BV, provided the vaginal pH is above 4.5. To test this hypothesis, a group of 113 women were first evaluated for BV by the standard set of clinical signs. Vaginal washes were collected, and aliquots were analyzed by quantitative culture for the concentration of G. vaginalis. Portions of these same samples were immobilized on nylon filters, along with standards for quantitation. The filters were incubated with a radiolabelled oligonucleotide specific for G. vaginalis 16S rRNA, and the subsequent autoradiographs were examined to determine levels of G. vaginalis in each sample. G. vaginalis at concentrations of greater than or equal to 2 x 10(7) CFU/ml and vaginal pH of greater than 4.5 were then analyzed for concurrence with the diagnoses based on clinical criteria. Results of this slot blot analysis gave a sensitivity of 95%, correctly categorizing 41 of 43 BV-positive specimens, and a specificity of 99%, correctly identifying 69 of 70 BV-negative specimens, compared with diagnosis based on clinical criteria.

Adult↗
PubMed2004

Evolving issues in understanding and treating bacterial vaginosis.

Bacterial vaginosis is a synergistic polymicrobial syndrome characterized by depletion of Lactobacillus spp., especially those that produce hydrogen peroxide, and an intense increase in the quantity of commensal vaginal anaerobic bacteria to 100- to 1000-fold above normal levels. While the bacterial spectrum of these organisms has long been known to include Gardnerella vaginalis, Prevotella spp., anaerobic Gram-positive cocci, Mobiluncus spp. and Mycoplasma hominis, innovative use of molecular diagnostics has identified novel species apparently associated with this syndrome, including Atopobium vaginalis. Effecting resolution of bacterial vaginosis is important, in particular for the 8 to 23% of women afflicted with symptomatic disease during their reproductive years. Bacterial vaginosis has been consistently associated with numerous adverse sequelae related to the upper genital tract, including pelvic inflammatory disease and postsurgical infection in the setting of invasive gynecologic procedures, and may increase women's risk of acquiring HIV infection. Pregnant women with bacterial vaginosis experience a higher rate of preterm delivery and low-birth-weight infants. While antibiotics with activity against anaerobes--typically, metronidazole and clindamycin applied vaginally or taken orally--are the mainstays of therapy, bacterial vaginosis frequently recurs. For these reasons, innovative approaches to therapy are urgently required.

Anti-Bacterial Agents↗
PubMed2004

Induced abortion: an overview for internists.

Internists care for many women who have had abortions and many who will seek abortions in the future. Each year, about 2% of all women of reproductive age have an abortion. Women having abortions tend to be young, white, unmarried, and early in pregnancy. Most abortions are done by suction curettage under local anesthesia in a freestanding clinic. However, medical abortion is growing in popularity as a nonsurgical alternative. The regimen approved by the U.S. Food and Drug Administration specifies mifepristone, 600 mg orally, followed 2 days later by misoprostol, 400 microg orally (within 49 days from last menses). Recent studies have recommended alternative approaches, such as mifepristone, 200 mg orally, followed in 1 to 3 days by misoprostol, 800 microg vaginally (up to 63 days). Medical abortion can be provided by a broader variety of physicians than can surgical abortion. The overall case-fatality rate for abortion is less than 1 death per 100,000 procedures. Infection, hemorrhage, acute hematometra, and retained tissue are among the more common complications. Referral back to the original abortion provider for management is advisable. Overall, induced abortion does not lead to late sequelae, either medical or psychiatric. Of importance, no link exists between induced abortion and later breast cancer. For physicians who are asked to help with a referral, the National Abortion Federation and Planned Parenthood Federation of America have helpful Web sites and networks of high-quality clinics. The cost of abortion (currently about 372 dollars at 10 weeks) has decreased in recent decades. Provision of ongoing contraception and encouragement of emergency contraception can reduce unintended pregnancies and the need for abortion.

Abortifacient Agents↗
PubMed1975

Psychohormonal treatment during the menopause.

Today the physician who treats women with emotional problems during menopause cannot function solely as a psychotherapist; he must deal with both their soma and psyche. The interaction between the endocrine and emotional states has long been known. When the equilibrium of an essentially normal state--menopause--is disturbed, a multifaceted approach is essential to restore homeostasis. Hormone replacement, psychotherapy and psychotropic drugs may all be necessary. Serial vaginal smears are useful in monitoring therapy.

Administration, Oral↗
PubMed2003

[Risk factors and screening strategy for group B streptococcal colonization in pregnant women: results of a prospective study].

OBJECTIVES: Group B Streptococcus (GBS) continues to be the most important bacterial cause of sepsis, meningitidis in newborns. American consensus guidelines have been published. They recommended the use of either risk-based strategy or screening-based approach for GBS colonization in pregnant women to identify candidates for intrapartum prophylaxis. Screening consists of obtaining vaginal and anorectal specimens for culture at 35 to 37 weeks' gestation. The aim of this prospective study was to assess the usefulness of systematic and concomitant GBS screening by rectal and vaginal swab in pregnant women. A questionnaire designed to determine the risk factors for colonization by GBS was completed. MATERIALS AND METHODS: We have screened 370 pregnant women with rectal and vaginal swab. RESULTS: Fifty seven (15.4%) women had positive GBS cultures. Of those women, the rectum and the vagina were the only site of colonization in 16 (4.3%) and 8 (2.2%) women respectively. None of the factors studied was significantly associated with GBS colonization. CONCLUSION: Detection of GBS is enhanced by 40% by using vaginal and anorectal swabs compared to a vaginal swab alone. No studied factor appeared to predict GBS colonization, which incited us to screen all pregnant women.

Adult↗
PubMed1992

Laparoscopic hysterectomy.

Approximately 600,000 hysterectomies are performed each year in the United States, more than 75% of which are removed via an open laparotomy. Most hysterectomies that currently require an abdominal approach may be performed with laparoscopic dissection of part or all of the abdominal portion, followed by vaginal removal of the specimen. Indications for laparoscopic-guided hysterectomy include endometriosis, extensive fibroid disease, adnexal masses, adhesions from prior surgery, or inflammatory disease. Laparoscopic hysterectomy may also be considered for stage I endometrial, ovarian, and cervical cancer.

Female↗
PubMed1992

Conservative management of splenic subcapsular hematoma in the third trimester of pregnancy. A case report.

A delayed splenic hemorrhage from a subcapsular hematoma occurred in association with pregnancy. That rare complication carries a high mortality rate, is rarely diagnosed preoperatively and is correctly diagnosed only 20% of the time. The clinical setting and a high index of suspicion led us to investigate for the presence of a splenic hematoma. A computed tomographic scan was invaluable in establishing the diagnosis. We adopted a conservative approach and followed the patient's clinical course from 28 to 40 weeks' gestation, until she delivered vaginally. In general, patient management (conservative vs. splenectomy) and mode of delivery will depend on how close one is to the initial event, on the patient's and fetus's clinical condition and on the gestational age.

Accidents, Traffic↗
PubMed1990

[Neonatal hydrocolpos with distal vaginal atresia. Apropos of 2 cases].

Two cases of neonatal hydrocolpos due to distal vaginal atresia is reported where hydro-vaginal distension produced respiratory distress and bowel obstruction radiologic and ultrasonic studies established the diagnostic of hydrocolpos surgery combining abdomino-perineal approaches was successfully done. In this occasion the authors emphasize the characteristics of this abnormality with review of literature and insist on the major interest of prenatal diagnostic in taking early infants.

Female↗
PubMed2004

A monte carlo dosimetry study of vaginal 192Ir brachytherapy applications with a shielded cylindrical applicator set.

A durable recommendation for brachytherapy treatment planning systems to account for the effect of tissue, applicator and shielding material heterogeneities exists. As different proposed approaches have not been integrated in clinical treatment planning routine yet, currently utilized systems disregard or, most commonly, do not fully account for the aforementioned effects. Therefore, it is of interest to evaluate the efficacy of current treatment planning in clinical applications susceptible to errors due to heterogeneities. In this work the effect of the internal structure as well as the shielding used with a commercially available cylindrical shielded applicator set (Nucletron part # 084.320) for vaginal and rectum treatments is studied using three-dimensional Monte Carlo simulation for a clinical treatment plan involving seven source dwell positions of the classic microSelectron HDR 192Ir source. Results are compared to calculations of a treatment planning system (Plato BPS v.14.2.7), which assumes homogeneous water medium and applies a constant, multiplicative transmission factor only at points lying in the shadow of the shield. It is found that the internal structure of the applicator (which includes stainless steel, air and plastic materials) with no shield loaded does not affect the dose distribution relative to homogeneous water. In the unshielded side of the applicator with a 90 degrees, 180 degrees, or 270 degrees tungsten alloy shield loaded, an overestimation of treatment planning system calculations relative to Monte Carlo results was observed which is both shield and position dependent. While significant (up to 15%) at increased distances, which are not of major clinical importance, this overestimation does not affect dose prescription distances by more than 3%. The inverse effect of approx. 3% dose increase at dose prescription distances is observed for stainless steel shields. Regarding the shielded side of the applicator, it is shown that the default treatment planning system transmission factors for tungsten alloy result in a consistent dose over-estimation thus constituting a safe approach given the nature of associated clinical applications. Stainless steel is shown to be an ineffective shielding material with transmission factors reaching up to 0.68 at increased distances irrespective of shield geometry.

Body Burden↗
PubMed1995

Evolution of the methods of neovaginoplasty for vaginal aplasia.

The aim of vaginoplasty should be the creation without excessive morbidity of a neovagina that will be satisfying in appearance, function and feeling. The multitude of methods described in the literature indicates the fact that an ideal approach has not yet been found. In this paper the various methods are described and discussed. It is concluded that the non-operative impression technique, the peritoneum pull-through technique and the use of skin grafts are methods of choice. In cases where immediate vaginal reconstruction after oncological surgery is indicated, myocutaneous flaps are preferred. Only in cases in which other methods have failed should recto-sigmoid transplantation be considered.

Colon, Sigmoid↗
PubMed1998

Uterus didelphys with unilateral imperforate hemivagina and ipsilateral renal agenesis.

Eight patients with a double uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis are described. The most common clinical presentation was that of the onset of pelvic pain and dysmenorrhea, in association with the finding of a pelvic mass. In seven patients, a window was created between two vaginae by transvaginal route. In one patient, the blind vagina with hematocolpos and attending uterus were extirpated by an abdominal approach. The postoperative courses were uncomplicated in all patients. A greater awareness of this syndrome should lead to accurate diagnosis. Excision of the obstructing vaginal septum offers a complete relief of symptoms while preserving reproductive capacity.

Abnormalities, Multiple↗
PubMed2001

An Update on Vaginal Microbicides.

In response to an increasing prevalence of sexually transmitted diseases, especially AIDS, efforts to prevent further infections have been heightened. One of those approaches has been the development of topical microbicidal agents or microbicides. These are compounds designed to protect the body's mucosal surfaces from infection by sexually transmitted disease-causing pathogens. Numerous candidates are currently in preclinical stages; however, only a handful have been tested for safety, and even fewer are ready for clinical efficacy trials. In this update, we describe some of the specific features of microbicide research and development, including preclinical screening algorithms, candidate's ideal properties, examples of compounds presently in the pipeline, and future prospects.

Journal Article↗
PubMed2005

Vaginal versus transabdominal hysterectomy: is mode of hysterectomy to influence pelvic statics or is pelvic statics to influence mode of hysterectomy?

BACKGROUND: To check the hypothesis that the mobility of the urethrovesical junction in the preoperative phase is different in women that will undergo either vaginal, abdominal, or laparoscopic-assisted vaginal hysterectomy. METHODS: Eighty-seven consecutive hysterectomies, carried out between January 1999 and December 2001 in our Department, were retrospectively considered. The type of surgical procedure as well as the approach was decided by the surgeon, according to personal experience. Each patient underwent a preoperative transperineal ultrasound, measuring urethral mobility. The ultrasounds were repeated 1 month and 1 year after surgery. RESULTS: In 35 out of 36 women (97.2%) that underwent vaginal hysterectomy and in nine out of 12 (75%) that underwent laparoscopic-assisted vaginal hysterectomy, we detected a high level of urethral mobility in the preoperative phase, compared with nine out of 39 (23.1%) women that underwent transabdominal hysterectomy. CONCLUSIONS: The results of our study allow us to confirm our starting hypothesis. Statistical analysis highlights that preoperative data are significantly different for the three types of hysterectomies, both as urethral mobility values (analysis of variance P<or=0.0001) and as relative frequency of patients at higher risk of pelvic statics alterations (chi2 test P<or=0.0001).

Adult↗
PubMed1998

[Celio-assisted vaginal surgery].

BACKGROUND: Remarkable progress has been made in laparoscopic surgery over the past few years. The evolution of laparoscopic techniques has enabled surgeons to undertake celio-assisted vaginal operations. In particular, the possibility of using mechanical retractors to lift the abdominal wall as an alternative to pneumoperitoneum now enables surgeons to operate simultaneously using a transvaginal and laparoscopic approach. Gas-free laparoscopy has introduced a new and very interesting concept of laparovaginal surgery. The uterus is in fact both an abdominal and pelvic organ and can therefore be reached more easily and with greater safety using a combined vaginal and laparoscopic technique. METHODS: A group of 17 patients underwent celio-assisted vaginal surgery. A prospective study was performed in patients with indications for vaginal operations who had given their informed consent to the use of this new surgical technique. Their mean age was 49.4 years. Mean parity was 1. RESULTS: Vaginal myomectomy was performed in 58.8% of cases, whereas 41.2% underwent vaginal hysterectomy. Laparoconversion was necessary in 17.6% of cases. Postoperative complications were rare (11.7%). The mean duration of surgery was 122.7 minutes. Mean hospital stay was 3.7 days. CONCLUSIONS: The considerable advantages of celio-assisted vaginal surgery using gas-free laparoscopy may be summed up as reduced operating time and reduced intra-abdominal pressure which significantly diminish the risk of thromboembolism. The disadvantages that were noted compared to pneumoperitoneum include: diminished lateral exposure of the abdominal cavity and paracholic grooves, reduced lifting of the rib margin and a greater presence of the intestinal ansae in the laparoscopic visual field in obese patients.

Abdomen↗
PubMed2001

The effect of introduction of a guideline on the management of vaginal discharge and in particular bacterial vaginosis in primary care.

BACKGROUND: Bacterial vaginosis (BV) is the commonest cause of vaginal discharge, and its association with obstetric and gynaecological complications is being recognized increasingly. It was our impression that BV was poorly understood and underdiagnosed in family practice. OBJECTIVE: The aim of this study was to explore the management of patients with vaginal symptoms by family practitioners and to see if the management changed after the assimilation of best practice guidelines. METHOD: Family practitioners were invited to complete a baseline questionnaire of their perceived practice, and to record actual practice when consulted about vaginal symptoms, for a minimum of 4 weeks. Consensus best practice guidelines were then provided and practice recorded for a similar period. RESULTS: Baseline data was received from 34 practitioners and suggested that the symptoms and signs of different vaginal infections were not well known. Most symptomatic patients were only investigated at re-presentation with unresolved symptoms or at recurrence, and 43% of respondents treated with empirical antifungals as a first line approach. Pregnant patients were only occasionally asked about symptoms and only occasionally examined if symptomatic. Pre-guideline practice data from 30 practitioners showed 1.2 patient consultations/week, of which 60% were examined and 55% had a high vaginal swab (HVS) sent. Only 2% had near-patient tests done. Post-guideline data from 23 family practitioners showed a lower recorded consultation rate at 0.7/week, but 90% of these were examined, 77% had an HVS sent and 69% had near-patient tests done. Of the 36 HVS examined by Gram stain, 19 (53%) showed Lactobacillus predominant flora and 10 (28%) suggested BV. Seven (19%) were borderline or ungradable. Only three (8%) showed yeasts, one of which also showed BV. CONCLUSIONS: Baseline data supported our impression that BV was under-recognized. Guidelines appeared to improve the rate of investigation of women consulting with vaginal symptoms.

Algorithms↗
PubMed1999

Pelvic organ prolapse: anterior, superior, and posterior vaginal segment defects.

Pelvic organ prolapse is a complex entity that potentially involves not only poor support for multiple sites in the vagina but also the function of the urethra, bladder, and anorectum, as well as sexual function. We must provide a comprehensive approach to the evaluation and management of women with pelvic organ prolapse and must critically review the assessment of surgical management.

Female↗
PubMed2000

Sex workers' perspectives on condom use for oral sex with clients: a qualitative study.

The authors conducted in-depth interviews with 46 female brothel-based sex workers to explore their perceived barriers and approaches in getting clients to use condoms for oral sex. Reasons given by sex workers for not using condoms for oral sex as compared to vaginal sex included self-perception of low vulnerability to AIDS and sexually transmitted infections, misconceptions on transmission of the HIV virus, lack of negotiation skills, lack of support from brothel keepers and peers, and unpleasant taste and smell of condoms. Some sex workers could get all their clients to use condoms for oral sex by using negotiation skills, including the positive approach, the fear approach, the emotional appeal approach, and the assertive approach. Findings from this study would help design more appropriate messages and improve negotiation skills of sex workers to increase consistent condom use for oral sex.

Acquired Immunodeficiency Syndrome↗