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OBSTETRICS
Cancer in Pregnancy
GYNAECOLOGY
Hysterectomy for Benign
Gynaecology Disease
CME ARTICLE
Adolescent Menstrual
Problems
YOUR PARTNER IN PAEDIATRIC AND O&G PRACTICE
JOURNAL WATCH
Editorial Board
Board Director, Paediatrics
Professor Pik-To Cheung
Associate Professor
Raymond Hang Wun Li
Dr Tan Ah Moy
Singapore
Dr Rajeshwar Rao
Dr Kwok-Yin Leung
Dr Tak-Yeung Leung
Professor SC Ng
Professor Hextan
Dr Wing-Cheong Leung
45
Children with mild hearing loss also
benefit from the use of hearing aids
Post-mortem serum vitamin D
valuable for assessing sudden death
in children
46
Oral immunotherapy effective at desensitising children
with peanut allergy
Dairy consumption at age 10 not related with excess
fat in late childhood
Fracture incidence can occur early after therapy for
breast or gynaecological cancer
47
Provision of free education,
contraception can reduce
unintended teen pregnancies
48
Mental anxiety, depression mediate the association
between childhood eczema or asthma and child
mental wellbeing
Psychological interventions improve pregnancy rates
in infertile couples
REVIEW ARTICLE
PAEDIATRICS
49
Hair Loss in Infancy and Childhood
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Cancer in Pregnancy
iii
iv
GYNAECOLOGY
CONTINUING
MEDICAL EDUCATION
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81
REVIEW ARTICLE
1 POINT
Case Studies
Pictorial Medicine
JOURNAL WATCH
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of hearing aid use with speech and language outcomes among 180 3- and
5-year-old children with hearing loss. All
Paediatrics
provided by the hearing aids were significantly, but modestly, correlated with levels of speech and language in children
with mild as well as moderate-to-severe
hearing loss. Increased duration of hearing aid use was associated with greater
benefits for both speech and language
development.
The researchers conclude that their
findings support the early provision of
well-fitted hearing aids for all children
with hearing loss, even those with mild
impairments.
Tomblin JB et al. The influence of hearing aids on the speech
and language development of children with hearing loss.
JAMA Otolaryngol Head Neck Surg 2014;140:403409.
by UK researchers.
ethnic group.
45
46
GYNAECOLOGY
JOURNAL
WATCH
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the trial.
duced- or full-fat.
Anagnostou K et al. Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children
(STOP II): a phase 2 randomised controlled trial. Lancet
2014;38312971304.
G
Gynaecology
Fracture incidence can occur
early after therapy for breast or
gynaecological cancer
JOURNAL WATCH
PEER REVIEWED
significantly shorter among patients older than 70 years (1.2 years), compared
with those aged 5059 years (3.2 years).
Hui SK et al. Spatial and temporal fracture pattern in breast
and gynecologic cancer survivors. Journal of Cancer
2015;6:6669.
O
Obstetrics
Provision of free education,
contraception can reduce
unintended teen pregnancies
Women who undergo cancer therapy
reversible
contraception,
according
CHOICE project.
cohort
pattern
The
skeletal
fracture
This
large,
prospective
47
48
GYNAECOLOGY
JOURNAL
WATCH
PEER REVIEWED
teenage pregnancies.
children.
Secura GM et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014;371:1316
1323.
Maternal anxiety,
depression mediate the
association between childhood
eczema or asthma and child
mental wellbeing
Maternal mental health appears to medi-
Teyhan A et al. Child allergic symptoms and mental well-being: the role of maternal anxiety and depression. J Pediatr
2014;165:592599.e5.
Psychological interventions
improve pregnancy rates
in infertile couples
Childhood
hyperactive)
problems.
women.
Psychosocial
interventions
were
Con
01
ust 2
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u
A
2
20-2
pore
a
g
n
i
5S
City
affles
ntre
Ce
n
o
i
t
n
ve
The Synthesis of
Evidence, Experience,
and Choice in
Womens Health
Call for Abstracts, Registration,
and Programme at
www.sicog2015.com
PAEDIATRICS
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Paul Farrant,
Hair problems in children are not uncommon and can cause considerable
anxiety among parents and children. Conditions such as alopecia areata and
trichotillomania can present in both adults and children but in children one also
needs to consider rarer congenital and hereditary causes of hair loss which can
occasionally present as part of a multisystem syndrome. A practical approach to
evaluating hair disorders in children is crucial to ensure the correct diagnosis is
made.
INTRODUCTION
such as alopecia areata and trichotillomania can present in both adults and
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50
PAEDIATRICS
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Sebaceous gland
Pili muscle
Isthmus
EVALUATION OF A CHILD
WITH HAIR LOSS
History
It is important to establish whether hair was normal at birth, when hair loss began and whether
this was diffuse loss, patchy loss or failure to
grow. Symptoms such as itch or burning are often
associated with inflammation (rare) or infection or
infestation (both common). Details of teeth and
Dermal sheath
Hair bulb
Dermal papilla
Clinical Evaluation
PAEDIATRICS
PEER REVIEWED
Anagen
Catagen
(Regression phase)
hair shaft disorders. Abnormal hair fibre production can produce unruly hair due to hairs being ir-
Sebaceous gland
Epithelial column
3 months
Hair matrix
Dermal papilla
Exogen
Telogen
(Exit phase)
Condition
Telogen effluvium
Alopecia areata
or oval patch of alopecia in the fronto-temporal region (Figure 4). Most are
unilateral with the base of the triangle orientated forwards and fine vellus
hairs are present in the affected area. Due to the location and typical lancet
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PAEDIATRICS
PEER REVIEWED
Anagen
Figure 3. Telogen Hair with De-pigmented Bulb and Anagen Hair Showing
Pigmented Bulb Enclosed Within its Root Sheath.
rie Unna hypotrichosis is an autosomal dominant disorder which presents during childhood
PAEDIATRICS
PEER REVIEWED
is more common in girls and predominantly affects children with fair skin and blond hair. The
hair is normal at birth but later becomes sparse
or fails to grow long. A gentle hair pull will painlessly remove anagen hairs. Light microscopy of
extracted hairs will reveal dysplastic anagen hairs
with misshapen bulbs. This condition may resolve
spontaneously with age.
Monilethrix: this defect of hair keratins is inherited in an autosomal dominant pattern. It results
in beading (wide and narrow zones in the hair
and are fragile (Figure 6). Not all hairs are af-
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PAEDIATRICS
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abnormality usually becomes noticeable in infancy with the development of short, sparse, brittle
and fragile hair. The eyebrows and eyelashes are
usually sparse or absent. Light microscopy will
show areas where the distal hair shaft invaginates
into the proximal hair shaft. The hair may improve
with age as the follicles thicken but defects in eyebrow and body hair tend to persist.
Trichorrhexis
Invaginata
Pili torti
Trichorrhexis
Nodosa
PAEDIATRICS
PEER REVIEWED
Figure 7. Uncombable Hair Showing Triangular Hairs on Microscopy and Unruly Spun Glass Hair.
age.
or Carvajal disease.
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PAEDIATRICS
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Alopecia Areata
(See below).
Other presentations include AT, AU, ophiasis pattern and rarely a diffuse variant with widespread
in many cases and may be the only sites affected. Regrowth can be fine and depigmented at
PAEDIATRICS
PEER REVIEWED
spontaneous remission is possible or when effective treatments are unlikely to be tolerated well. In
such situations a wig, headscarf and semi-permanent tattoos can be helpful. In limited patchy
hair loss potent topical steroids with or without
occlusion and intralesional steroids may induce
hair growth but can cause skin atrophy. Discomfort from injections restricts its use in young
children. For more extensive patchy hair loss
or AT/AU systemic corticosteroids can produce
regrowth but this is often not sustained and the
risks may outweigh the benefits. Contact immunotherapy has been shown to be effective but is
not widely available and can be difficult and disruptive in young children as it needs to be repeated frequently (weekly).
Trichotillomania
This is a behavioural disorder characterised by
compulsive hair pulling or plucking. It occurs in
two main forms. In infants and young children it
represents a habit tic similar to thumb sucking.
It is more common in boys and usually resolves
spontaneously. In older children and adolescents
it is seen predominantly in females often with evidence of psychological or behavioural stress.
This form is characterised by the American Psychiatric Association as an impulse control disorder where irresistible hair pulling results in release
of tension and distress. Hair is most commonly
Tinea Capitis
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PAEDIATRICS
Practice Points
PEER REVIEWED
Scarring Alopecia
Scarring or cicatricial alopecia implies permanent hair loss associated with destruction of
hair follicles. This can result from a disease that
affects the follicles primarily or a secondary external process. Examples of secondary causes
include burns, radio-dermatitis, morphoea and
infections such as the favus form of tinea capitis. Primary scarring alopecia in children is extremely rare. In African American girls traction
alopecia can result in a permanent alopecia if
traction from hair styling is excessive and prolonged. Initially however the hair loss is temporary and behaves like a non-scarring alopecia.
CONCLUSION
An understanding of the basic hair biology
improves the assessment of a child with hair
problems and helps to explain why some
lymphadenopathy.
the diagnosis. Oral antifungal agents are needed to ensure eradication but combined use with
topical treatment such as ketaconazole shampoo
may reduce the risk of transmission. Although
not licensed in children, oral terbinafine is generally recommended as it is particularly effective
for the Trichophyton species. It is fungicidal and
the duration of treatment (2 to 4 weeks) is shorter
than griseofulvin, a fungistatic agent. For infection
with Microsporum species however griseofulvin
Further Reading
remains the treatment of choice. Combs, brushes, hats etc should be disinfected or discarded
Caroline Champagne is a specialist registrar in the Dermatology Department. The Churchill Hospital, Oxford, UK. Conflicts of interest:
none. Paul Farrant MBBS BSc FRCP is a Consultant Dermatologist
in the Dermatology Department, Brighton General Hospital, Brighton,
UK. Conflicts of interest: none.
OBSTETRICS
PEER REVIEWED
Cancer in Pregnancy
Ayshini Samarasinghe, MBBS BSc; Mahmood I Shafi, MBBCh MD DA FRCOG
INTRODUCTION
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OBSTETRICS
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Procedure
Chest X-ray
0.00006
Abdominal X-ray
0.15-0.26
Pelvic X-ray
0.2-0.35
Intravenous Pyelography
0.4-09
Barium enema
0.3-4
Mammograph
0.01-0.04
CT Thorax
0.01-1.3
CT Abdomen
0.8-3
CT Pelvis
2.5-8.9
MANAGEMENT
The thought process for management is essen-
a multidisciplinary team, including system specialists, oncologists, obstetricians, perinatalologists, paediatrician, psychologists, radiologists
and specialist nurses (Figure 1).
TREATMENT
Surgery
challenge of balancing optimal maternal treatment
Systemic Treatment
at exposure.
OBSTETRICS
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Malignancy
suspected
Need to
confirm diagnosis
and Vinblastin.
Specific cytotoxic drug effects are difficult to
describe as combinations are frequently used.
The decision to administer chemotherapy
Take appropriate
biopsies
Consider
gestational age
Stage with
imaging (MRI)
or surgery as
appropriate
the fetus and oncology treatment schedule. Delivery should be planned at least 3 weeks after the
last cycle of chemotherapy to allow bone marrow
recovery to reduce the risk of haemorrhage and
sepsis.
Supportive and symptom control therapy
can be given according to general recommendations (Table 2). Corticoids, methylprednisolone
and hydrocortisone are extensively metabolized
1st
Trimester
2nd/3rd
trimester
Will termination of
pregnancy aid maternal
management and
improve prognosis?
Will treatment
affect pregnancy?
Thromboprophylaxis
YES
NO
NO
YES
Proceed with
treatment
ORGAN PATHOLOGY
Gynaecological Malignancies
Consider delay of
treatment until fetal
maturity and delivery
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OBSTETRICS
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Medication
Safety
Metoclopramide
5-HT antagonists
Corticoids
Granulocyte colony-stimulating
factors
Eythropoetins
Paracetamol
or uterine origin that are found at the time of an1,000 incidence of ovarian tumours in pregnancy. The risk of malignancy of these is 3 to 6%.
The histological presentation is shown in Table
Histology
Frequency (%)
Germ cell
6-40
Boderline
21-35
Epithilial
28-30
Sex-cord stromal
9-16
Other
3-5
tumour markers in pregnancy. A laparoscopic approach to surgery is feasible if less than 16 weeks
OBSTETRICS
PEER REVIEWED
Colposcopy
during pregnancy
No suspected
invasion
Suspected
invasion
Serial
colposcopy and
cytology each
trimester
Wedge/cone
biopsy
No progression
either
colposcopically
or cytologically
Early invasion
(Stage 1a1) or less
Invasion
confirmed
Await
delivery
Postpartum
assessment at
three months
and treatment
plete molar pregnancies are diploid and androgenic, with no evidence of fetal tissue. These arise
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OBSTETRICS
PEER REVIEWED
Breast lump
in pregnancy
Imaging
(Ultrasound,
mammography)
and core biopsy
<12/40
Locally advanced
>12/40
Consider
termination and
standard treatment
Breast conserving
surgery or mastectomy,
sentinal node procedure
or axillary node dissection.
Adjuvant chemotherapy
from 14 weeks onwards.
Radiotherapy is not
considered until
after delivery
Neoadjuvant
chemotherapy
Deliver
>3537/40
Completion
of treatment
Hodgkins Lymphoma (NHL) and acute leukaemia. The treatment depends on the type of cancer
and the gestational age (Table 4).
Lymphoma: with a prevalence of 1 in 6,000 pregnancies, lymphoma is the fourth most common
Other Malignancies
OBSTETRICS
PEER REVIEWED
Therapies
Maternal
Outcome
Fetal
Outcome
Generally
unaffected
Generally
unaffected
Generally
unaffected
Generally
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Generally
unaffected
Generally
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Multidrug chemotherapy
Multidrug chemotherapy
Asymptomatic Myeloma
All pregnancy stages
Monitor carefully
Symptomatic Myeloma
1st Trimester
Termination and therapy
as non-pregnant women
2nd/3rd Trimester
Treat as non-pregnant .
But avoid lenalidomide and
thalidomide
Hodgkins Lymphoma
1st Trimester
Defer treatment to 2nd
trimester
2nd/3rd Trimester
Treat as non-pregnant
Chemotherapy
Chemotherapy
If earlier
treatment
needed, then
termination
Unaffected
2nd/3rd Trimester
Treat as non-pregnant
Multidrug chemotherapy.
Consider allogenic stem cell
transplant
Multidrug chemotherapy
Unaffected
Pregnancy
termination
Probably
unaffected
Probably
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Multidrug chemotherapy
Unaffected
Multidrug chemotherapy
Probably
unaffected
Pregnancy
termination
Probably
unaffected
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OBSTETRICS
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Termination of Pregnancy is Recommended if Acute Leukaemia is Diagnosed in the First Trimester due to the Teratogenic Effects of
Chemotherapy.
to rise due to increase in maternal age and the
Radioisotope scans are not advised. If well differentiated the treatment ranges from lobectomy to
cancer.
OBSTETRICS
PEER REVIEWED
Obstetric Monitoring in Pregnancies Where there is Co-existing Cancer Should be the Same as for High-risk Pregnancies.
Melanoma: the incidence of melanoma has been
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OBSTETRICS
Practice Points
PEER REVIEWED
can lead to long-term emotional trauma. A diagnosis of cancer in pregnancy leads to anxiety
workers.
A multidisciplinary approach is vital when constructing a
treatment plan taking into account the parents wishes along with
the best practice treatment for the malignancy.
metastases, but fetal spread has never been described for gynaecological cancers.
SUMMARY
An individualised action plan is crucial for cancer
Psychosocial Impact
Women diagnosed with cancer experience
complex emotions, which are distressing and
Further Reading
Expert Opinion
INTERVIEW
Denominator
Cost (Euro)
eHF-C
Cost (Euro)
eHF-W
Cost (Euro)
pHF-W
Societal
Child treated
-478
-42
-430
Case prevented
-4345
-1386
-5404
Child treated
73
110
-31
Case prevented
667
3626
-392
Health insurance
eHF-C: extensively hydrolyzed casein formula; eHF-W: extensively hydrolyzed whey formula;
pHF-W: partially hydrolyzed whey formula.
observational studies
causality is likely.15,16
and
that
reverse
GYNAECOLOGY
PEER REVIEWED
MD MRCOG;
Isaac Manyonda,
Despite the advent of newer, and in some instances less invasive, interventions for
the management of abnormal uterine bleeding, hysterectomy remains the most commonly performed major gynaecological operation. It continues to score highest in satisfaction rates. It is therefore imperative that all aspects of this operation are reviewed
on a regular basis. For example, all evidence suggests that the vaginal route is the
safest, most cost-effective approach affording rapid recovery, yet the majority of hysterectomies are still performed by the abdominal route. Newer approaches such as
robotic surgery have captured the imagination of the enthusiasts, yet this approach
is hugely expensive, and there are no data justifying its use over the laparoscopic
or indeed the conventional approach. Quality of life should remain the principal outcome measure for hysterectomy for benign disease, and therefore the impact of the
various approaches to hysterectomy should address this outcome. Complications of
any new approach should be addressed, and the question that continues to elude
an answer, namely why there are such widely and wildly varying rates of hysterectomy between surgeons in one hospital, between hospitals in one region, between
the regions and between countries, should continue to be addressed, and perhaps
one day the definitive study that will answer the question will be undertaken.
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GYNAECOLOGY
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Hysterectomy Remains the Most Common Major Gynaecological Operation Performed Worldwide.
INTRODUCTION
GYNAECOLOGY
PEER REVIEWED
VARIOUS ROUTES OF
HYSTERECTOMY: OUTCOMES
AND COST-EFFECTIVENESS
The three popular approaches to hysterectomy
for benign diseases are abdominal hysterectomy, vaginal hysterectomy (VH) and laparoscopic
hysterectomy. Laparoscopic hysterectomy has
three further subdivisions: laparoscopic assisted
vaginal hysterectomy (LAVH) in which a vaginal
hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation,
laparoscopic subtotal hysterectomy, and total
laparoscopic hysterectomy (TLH), where there is
no vaginal component, and the vault is sutured
laparoscopically. It is now widely believed that
vaginal hysterectomy should be a standard de-
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GYNAECOLOGY
PEER REVIEWED
When Comparing LaparoscopicTotal Versus Subtotal Hysterectomy, the Former is Associated with More Short-term Complications
Whereas the Latter is Associated with More Long-term Complications.
vaginal hysterectomy, it was reported that lap-
SUPRACERVICAL HYSTERECTOMY/
SUBTOTAL HYSTERECTOMY
GYNAECOLOGY
PEER REVIEWED
or bowel function.
ALTERNATIVES TO HYSTERECTOMY
AND CURRENT STAND IN THE
UNITED KINGDOM
ROBOTICALLY ASSISTED
HYSTERECTOMIES
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GYNAECOLOGY
PEER REVIEWED
riculum.
OVARIAN CONSERVATION
AT HYSTERECTOMY
symptomatic fibroids.
GYNAECOLOGY
PEER REVIEWED
COMPLICATIONS
OF HYSTERECTOMY
Although some of the issues on complications
have been touched upon during the discussion
on the advantages and disadvantages of various
There are Emerging Data that Suggest that Ovarian Preservation may
be Beneficial Even up to 65 Years of Age.
an important topic.
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GYNAECOLOGY
PEER REVIEWED
omoniasis.
mance of hospitals.
GYNAECOLOGY
PEER REVIEWED
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GYNAECOLOGY
PEER REVIEWED
terectomy is a clinically highly effective intervention in terms of cure and improvement in quality
of life, its cost, with regard to both the method/
route as well as alternative treatments, has to be
considered. Cost-effectiveness analysis (CEA) is
a system that evaluates both costs and health
outcomes in order to compare healthcare programmes. Healthcare funding agencies such
as the NHS and NICE require that only direct
health related costs are included in that analysis.
The outcome of CEA is sometimes expressed
as cost-effectiveness ratio. In this ratio, all costs
(resources consumed less savings associated
with the intervention) are included in the numerator and all health outcomes (benefits less harm)
are included in the denominator. However CEA
is technically challenging and is often based on
ill-founded and misleading assumptions. It is beyond the scope of this chapter to discuss CEA in
detail, so the current received wisdom is summarised below.
Although expensive, all CEA of hysterectomy
From an Economic Point of View, the Laparoscopic Route is to be Preferred
Only when Vaginal Hysterectomy is not Possible.
HEALTH ECONOMICS
OF HYSTERECTOMY
GYNAECOLOGY
PEER REVIEWED
INNOVATIVE APPROACHES
TO HYSTERECTOMY
Practice Points
The vast majority of hysterectomies are performed via the
abdominal route, although research suggests that the vaginal
route might be more advantageous.
Uterine fibroids are the commonest indication for hysterectomy.
It is a safe operation, with mortality rates being 0.5 to 2 per 1,000.
Some of the complications are infection, venous thromboembolism,
haemorrhage, visceral damage and vaginal cuff dehiscence. There
is no difference in urinary tract damage amongst the subtypes of
hysterectomy and between abdominal and vaginal hysterectomy,
however the risk is more in laparoscopic in comparison to both
abdominal and vaginal.
Robotic assisted vaginal hysterectomy does not confer any
significant advantage over conventional laparoscopic hysterectomy,
however it is significantly more expensive.
Conservative alternatives to hysterectomy, including endometrial
ablative techniques, the Mirena IUS, and uterine artery embolisation
for fibroids have not greatly reduced hysterectomy rates.
Hysterectomy remains the most cost-effective modality in the
treatment of menorrhagia.
Hysterectomy rates vary widely between regions, and even within
the same geographical area, the reason for which is widely
unknown.
Innovative approaches such as TSPLH and NOTES should be
viewed with cautious optimism and robust research needs to take
place before they can be introduced on a wide scale.
Preliminary results suggest that the peri-operative outcomes were similar, but when compared to in-patient vaginal hysterectomy, a cost
tion.
Single-port Laparoscopic
Hysterectomy (TSPLH)
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GYNAECOLOGY
PEER REVIEWED
Concluding Remarks
controlled trial by
of fibroids.
terectomy, why gynaecologists continue to perform hysterectomy through the abdominal route
Further Reading
1. Carlson K, Miller B, Fowler F. The Maine womens health study: outcomes of hysterectomy. Br J Obstet Gynaecol 1994;83:556565.
2. Clarke-Pearson DL, Geller EJ. Complications of hysterectomy 121:654
673.
3. Guo Y, Tian X, Wang L. Laparoscopically-assisted vaginal hysterectomy vs vaginal hysterectomy: meta analysis. J Minim Invasive Gynaecol
2013;20:1521.
4. Li M, Han Y, Feng YC. Single-port laparoscopic hysterectomy versus
conventional laparoscopic hysterectomy: a prospective randomized
trial. J Int Med Res 2012;40:7018.
5. Perera HK, Ananth CV, Richards C, et al. Variation in ovarian conservation in women undergoing hysterectomy for benign indications. Obstet
Gynaecol 2013;121:71726.
6. Su H, Yen CF, Wu KY, Han CM, Lee CL. Hysterectomy via transvaginal
natural orifice transluminal endoscopic surgery (NOTES): feasibility of
an innovative approach. Taiwan J Obstetrics Gynaecol 2012;51:217
21.
7. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda IT. A comparison
of outcomes following total and subtotal hysterectomies. N Engl J Med
2002;347:131825.
8. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best
Pract Res Clin Obstet Gynaecol 2005;19(3):40318.
9. Wright KN, Jonsdottir GM, Jorgensen S, Shah N, Einarsson JI. Costs
and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. JSLS 2012;16(4):51924.
10. Zakaria MA, Levy BS. Outpatients vaginal hysterectomy. Obstet Gynaecol 2012;120:135561.
2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and Reproductive Medicine 2014;24(5):135-140.
hysterectomy.
The suggested reading list at the end of this
chapter provides scope for more information for
the interested reader with regard to these new approaches to hysterectomy.
Adolescent Menstrual
Problems
Nik Rafiza Afendi,
1 POINT
INTRODUCTION
Menstrual problems are the commonest
gynaecological complaint in adolescent
females.
The most common menstrual problems seen in paediatric and adolescent
gynaecology (PAG) clinic include dysmenorrhoea, heavy menstrual bleeding,
oligomenorrhoea and amenorrhoea. The
incidence of the menstrual problems seen
in PAG clinic varies between countries. In
Hong Kong, 47% presented with menorrhagia, prolonged menstruation, and
short menstrual cycles, 30% had amenorrhoea (27% secondary amenorrhoea
and 3% primary amenorrhoea) , 12% had
dysmenorrhoea, 11% had oligomenorrhoea1, in comparison to the cases seen
in PAG clinic in Australia, 43% presented
with dysmenorrhoea followed by 28%
with heavy bleeding, 20% with oligomenorrhoea and 8% with amenorrhoea.2
Normal menstruation should be described in terms of frequency, regularity,
DYSMENORRHOEA
81
82
1. Pregnancy
1. Uterine/vaginal
Imperforate hymen
Transverse vaginal septum
Mullerian agenesis
2. Endocrine causes
Polycystic ovarian syndrome
Thyroid dysfunction
Late onset congenital adrenal
hyperplasia
Cushings disease
Premature ovarian failure
3. Acquired conditions
Stressed related hypothalamic
dysfunction
Eating disorder
Exercised induced amenorrhoea
Medications
4. Tumours
Ovarian tumours
Adrenal tumours
Prolactinomas
2. Ovarian
Premature ovarian failure
Autoimmune ovarian failure
Galactosaemia
Fragile X syndrome
Turner syndrome
Radio/chemotherapy
Swyer syndrome
Polycystic ovarian syndrome
3. Hypothalamic causes
Weight loss
Excessive exercise
Kallmann syndrome
Idiopathic
4. Delayed puberty
Constitutional
Chronic debilitating illness
Endocrine disorders, eg. thyroid
disease
5. Pituitary
Hypopituitarism
Hyperprolactinaemia
6. Hypothalamic/ pituitary
Head injury
Cranial tumours or irradiation
HEAVY MENSTRUAL
BLEEDING (HMB)
Previously HMB was known as menorrhagia. The causes of HMB are dysfunctional uterine bleeding (DUB), pelvic
pathology, medical disorders and coagulation disorders.
The most common cause of DUB in
adolescents is anovulation due to immaturity of the hypothamic-pituitary-ovarian
axis but bleeding disorders need to be
considered in this age group. Compared
dometriosis.
Primary
dysmenorrhoea
usually
gynaecologist.
OLIGOMENORRHOEA/
AMENORRHOEA
Oligomenorrhoea is defined as
POLYCYSTIC OVARIAN
SYNDROME
3,14
11
1.
Oligomenorrhoea and/or anovulation.
ism.
as well as fibrinogen.
10ml.
perplasia,
can be made.
Cushings
syndrome
and
83
84
PREMATURE OVARIAN
FAILURE
adolescents.16,17
16
16
17
16-17
others.
31
POF.
penia.24
aggregation.32
25
COCP
Gastro-
to 5 days.
Anti-Mullerian
Hormone
(AMH)
10,29,30
NSAIDS
85
86
tous.
in adolescents.37
flexible and frameless. It is a multicomponent system consisting of a non resorbable thread of which its proximal
end is provided with a single knot. The
FibroPlant-LNG IUS consists of a 3.5cm
long coaxial fibrous delivery system of
1.6mm in diameter, which delivers 14
and implanon.
ited.43
DMPA
MIRENA
polyethylene
Cyclical Progesterone
Cyclical progestogens taken for 21 days
39
33
is
small
1 year of use.44
40
treatment.
method.45
cents is limited.
Implant
CONCLUSION
REFERENCES
1. Chung PW, Chan SC, Yiu KW, Terence
TH Lao, Tony KH Chung. Menstrual disorders in a paediatric and adolescent gynaecology clinic: patient presentations and
longitudinal outcomes. Hong Kong Med J.
2011;17:391397
2. Abdul Ghani NA, Sanci L, Moore E,
Grover S. Parents perception of the impact
of menstrual problems on adolescents
quality of life. Oral abstract. doi:10.1016/j.
jpag.2010.01.015. Assessed on 21st Nov
2014
3. ACOG committee opinion no 349. Menstruation in girls and adolescents: using the
menstrual cycle as a vital sign. American
Academy of Pediatrics; American College
of Obstetricians and Gynaecologist. Obstet
Gynaecol. 2006;108:13231328
4. World Health Organization Multicenter
Study on Menstrual and Ovulatory Patterns in Adolescent Girls. I. A Multicenter
Cross-Sectional Study of Menarche. World
Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health
Care. 1986;7:229235
5. Read GF, Wilson DW, Hughes IA, et
al: The use of salivary progesterone assays in the assessment of ovarian function in postmenarchal girls. J Endocrinol.
1984;102:265
6. Vikho R, Apter D. Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. J Steroid Biochem.
1984;20:231236
7. Klein JR, Litt IF. Epidemiology of
adolescent
dysmenorrhea.
Pediatrics
1981;68:661-664
8. Juang CM, Yen MS, Twu NF, et al. Impact of pregnancy on primary dysmenorrhea. Int J Gynecol Obstet. 2006;92: 221
227
9. Cameron M, Moore P, Grover S. Uterus
Didelphys with obstructed Hemivagina//: A
case series. NASPAG 21st Annual Clinical
Meeting. doi:10.1016/j.jpag.2007.03.070.
Assessed on 20th Dec 2014
10. Wilkinson JP, Kadir RA .Management of
abnormal uterine bleeding. J Pediatr Adolesc Gynecol. 2010;23:S22S30
11. Lawrence SA, Teresa PA, William TG, et
al. Menorrhagia in adolescents with platelet function disorders: family history suggests further investigations. Oral Abstracts.
doi:10.1016/j.jpag.2009.01.056. Assessed
obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 1992;36:105
111
23. Ornstein RM, Copperman NM, Jacobson MS. Effect of Weight Loss on Menstrual
Function in Adolescents with Polycystic
Ovary Syndrome. J Pediatr Adolesc Gynecol. 2011;24:161165
24. Gallagher JC. Effect of early menopause on bone mineral density and fractures. Menopause. 2007;14:567571
25. Grynnerup AGA, Lindhard A, Srensen
S. Recent progress in the utility of anti-Mullerian hormone in female infertility. Curr
Opin Obstet Gynecol 2014;26:162167.
26. Freeman EW, Sammel MD, Lin H, Gracia CR. Antimullerian hormone as a predictor of time to menopause in late reproductive age women. J Clin Endocrinol Metab
2012;97:16731680.
27. Sowers MR, Eyvazzadeh AD, McConnell D, et al. Anti-mullerian hormone and
inhibin B in the definition of ovarian aging
and the menopause transition. J Clin Endocrinol Metab 2008;93:347883.
28.
Lethaby A, Farquhar C, Cooke I.
Antifibrinolytics for heavy menstrual
bleeding. Cochrane Database Syst Rev.
2000;(4):CD000249. Review.
29. Chi C, Pollard D, Tuddenham EG, et al.
Menorrhagia in adolescents with inherited
bleeding disorders. J Pediatr Adolesc Gynecol. 2010;23:215222
30. Roy SN, Bhattacharya S. Benefits and
risks of pharmacological agents used for
the treatment of menorrhagia. Drug saf.
2004;27:7590
31. Marjoribanks J, Proctor M, Farquhar
C, et al. Nonsteroidal anti-inflammatory
drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2010; (1): CD001751. doi:
10.1002/14651858.CD001751.pub2
32. Kadir RA, Lukes AS, Kouides PA, et al.
Management of excessive menstrual bleeding in women with hemostatic disorders.
Fertil Steril 2005;84:13521359
33. NICE guidance CG44. Heavy menstrual
bleeding. National Institute for Health and
Clinical Excellence; Jan 2007
34.
Gallo MF, Lopez LM, Grimes DA,
et al. Combination contraceptives: effects on weight. Cochrane Database
Syst Rev. 2014 Jan 29;1:CD003987.
doi:10.1002/14651858. CD003987.pub5.
87
88
CME QUESTIONS
CME ARTICLE
1 POINT
True False
1. Dysmenorrhoea in adolescents is usually due to endometriosis.
2. Ultrasound should be done for investigation of dysmenorrhoea in adolescents on
the first visit.
3. Ponstan can be safely used in treatment of menorrhagia in adolescents with
underlying bleeding disorder.
4. History of bleeding tendency in adolescents with heavy menstrual bleeding is
important.
5. Formal diagnosis of PCOS should not be made within 2 years of menarche.
6. Premature ovarian failure is mostly due to chromosomal abnormalities.
7. There is a small chance of spontaneous conception in patient with premature
ovarian failure.
8. 15 year old girl with normal secondary sexual characteristic who had not yet
attained menarche should be investigated for primary amenorrhoea.
9. NSAIDS can reduce the menstrual blood flow by 25 to 30% in women with heavy
menstrual bleeding.
10. Levonorgestrel intrauterine device is safe to be use in adolescents.
CME Answers
Date: ___________________________________________________
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The Secretariat
Hong Kong College of Obstetricians & Gynaecologists
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