Gynecological endocrinology patients attending Siriraj Hospital at the beginning of the new millennium.

Objective: The purpose of this study was to analyse the spectrum of new patients with gynecological endocrine abnormalities presenting to a teaching hospital in Bangkok at the beginning of the new millennium. The data obtained may help policy makers, involved health care providers and medical educators plan for the future to best suit the Thai new health care system, medical research or contemporary medical education in a teaching hospital. Methods: Only new patients attending the Gynecologic Endocrinology Clinic at Siriraj Hospital in the year 2000 (excluding natural and surgical menopause patients who separately attended the Menopause Clinic at that time) were included in the analysis. There were 492 new patients attending the clinic including newly referred patients from other departments at Siriraj Hospital or from other hospitals. Of these, 464 (94.3%) had complete records, full follow up and a conclusive final diagnosis. The data was analysed and presented in a descriptive manner. Results: Among 464 patients, the most common presenting symptom was abnormal uterine menstruation (85.5% of cases). The five most common final diagnoses were: endometrial hyperplasia (18.9%), Anovulatory DUB (14.4%), Endometriosis with histodiagnosis (13.7%), Polycystic ovary syndrome (5.1%) and premature ovarian failure (3.0%). Other uncommon diagnoses such as primary amenorrhea, which needs complicated investigations, caused by different etiologies (e.g. Mullerian agenesis, gonadal dysgenesis, androgen insensitivity syndrome), rare cases of secondary amenorrhea (e.g. late onset congenital adrenal hyperplasia, hypogonadotropic hypogonadism, pseudocyesis) were also seen at our clinic in the year 2000. Conclusion: The gynecologic endocrinology clinic of Siriraj Hospital had a great variety of number of cases and diagnoses, both common and uncommon. In most cases, problems could be evaluated and investigated at the outpatient clinic without admission. Treatments were also given and monitored effectively there. Only a few special investigations, such as chromosome analysis, CT or MRI were needed to obtain a final diagnosis. We expect to see a lower number of less complicated cases in the future who may be managed at a primary or a secondary care hospital. Nevertheless, knowledge about gynecological endocrinopathies are still of major importance for both undergraduates and postgraduates.

Pregnancy outcomes in methamphetamine abuse mothers.

Objective: The objective of this study was to determine the outcomes of pregnancy in methamphetamine abuse mothers. The history of methamphetamine abuse, other abused drugs and some abuse behaviors of mothers were also studied. Methods: Cross sectional analytical study of 182 mothers with a history of methamphetamine abuse during pregnancy and the outcomes were reviewed. Data was collected from in-patient files of Siriraj Hospital between 1 January 2000 and 31 December 2003. Those mothers who miscarried were excluded from the study. Characteristics of the patients, antenatal care records, histories of methamphetamine abuse, modes and outcomes of delivery such as preterm labor, birth weight, Apgar score, length and head circumferences were recorded. Subsequent analysis of 50 teenage mothers and 100 mothers over 20 years were compared. Data was analyzed and descriptive statistics, Chi-square test and unpaired t-test were used where appropriate. Results: Of all 182 mothers, 65.9% did not attend ANC and 43% were nulliparous. Percentages of preterm and low birth weight were 6.6% and 24.2% respectively. Sexually transmitted diseases were quite prevalent. There was a high positive anti-HIV rate of 6.6% in this group. Neonatal asphyxia (Apgar < 7) at 1 min was found in 4.9% of the infants. The average birth weight, head circumference and fetal length were 2813.5 + 456.3 gm., 32.0 + 2.1cm. and 48.4 + 2.7 cm. respectively. Most of the mothers abused methamphetamine less than one year with a dose of 1 tab per day. Multiple substance abuse was noticed. 47.9% of the patients smoked cigarettes and 12.7% consumed alcohol during pregnancy. Maternal characteristics and pregnancy outcomes were not different when subsequent analysis was performed to compare between 50 teenage mothers and 100 mothers over 20 years of age. Conclusion: The results showed some adverse outcomes of pregnancy from mothers with methamphetamine abuse. Poor ANC, high positive anti-HIV rates, high percentage of low birth weights and smaller head circumferences of the newborns were observed in this study. The prevalence of preterm was low without clear explanation. The age of the mothers had no additional role on these adverse outcomes although there was a trend of higher low birth weight and preterm among teenage mothers.

Effectiveness and safety of very low dose combined oral contraceptive for the treatment of non-atypical endometrial hyperplasia: A pilot study.

Objective: A randomized control study to compare the effectiveness and the safety of very low dose oral contraceptive (OC) with progestin for the treatment of endometrial hyperplasia. Methods: Ten patients with non-atypical endometrial hyperplasia who did not have contraindications for OC were randomized to receive either OC (Mercilon®) or progestin (Medroxy progesterone acetate: MPA) for 6 months at the Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. Their main measured outcomes were endometrial histopathology and adverse events. Results: Sixty percent (3 of 5) of the progestin group and 80% (4 of 5) of the OC group completed the 6-month therapy. All of them had normal endometrium by the end of the 6th cycle of treatment. Two cases in the progestin group and one case in the OC group withdrew from the study by the end of 1st cycle of treatment. No serious adverse event was detected during the study period. Conclusion: OC may be as effective and safe as progestin for the treatment of non-atypical endometrial hyperplasia.

Hormonal replacement therapy in surgical menopause with underlying endometriosis.

OBJECTIVE: To evaluate the effect of hormonal replacement therapy (HRT) regimens in surgical menopause patients with underlying endometriosis. DESIGN: Observational retrospective study. MATERIAL AND METHOD: 123 women with endometriosis after definite surgery (total abdominal hysterectomy with bilateral salpingo-oophorectomy) were followed in the Gynecologic Endocrinology and Menopause clinics. Patients were classified into 4 groups according to HRT regimens, i.e. control (no HRT, n=17), estrogen only (ERT, n=50), cyclic estrogen/progestin regimen (cyclic E/P, n=16), and continuous combined estrogen/progestin (ccE/P, n=24). 12 patients who received more than one regimen and 4 patients who received less than 6 months of HRT were excluded from the study. The information was obtained from the medical records. RESULTS: Mean age at surgery of all patients was 38.9 years old. Mean duration of HRT was 41.2 months. There was no difference in age at surgery or duration of follow-up in each group. There was 1 (2%) case of recurrent endometriosis and 3 (6%) cases of recurrent symptoms in the estrogen only group; none of them required additional surgical treatment. Malignant transformation was not found. CONCLUSIONS: Although the present series is small, it seems that HRT is safe for postmenopausal women with underlying endometriosis. Recurrence of endometriosis has rarely been a problem with HRT, especially in those who received the combination of estrogen and progestin regimens.

Sexuality in menopausal Thai women.

Objective : To evaluate the type and incidence of sexual problems and their relationship to vaginal problems and hormonal replacement therapy (HRT) in menopausal Thai women. Design : Cross-sectional study. Patients : 96 women, who were followed-up at the Menopause Clinic, Department of Obstetric Gynecology, Faculty of Medicine Siriraj Hospital from September 2001 to August 2002. Methods : All women were interviewed about sexual problems. The questionnaires requested demographic data, reproductive history, history of hormonal replacement therapy, postmenopausal complaints of sexual experience and responsiveness. Main outcome measurement : Types of sexual problems, the relationship between sexual and vaginal problems and the effect of HRT on sexuality. Results : Common sexual problems encountered after menopause were loss of libido, orgasmic dysfunction and dyspareunia. Both sexual desire and sexual activity decreased in the premenopausal period. Forty-three percent of natural menopausal women had sexual activity less than once a month. Similar results were found in the surgical groups. Only 24% of the subjects occasionally reached orgasm. Vaginal problems were found to have a significant relationship to the loss of sexual desire, whereas the decrease in vaginal secretion had significant relationship to the lack of orgasm. About 45.2% of menopausal women with HRT did not have a significant change in libido and sexual response. Conclusion : There is a decline in sexual response and activity in menopausal Thai women. Women with surgical menopause demonstrated a similar kind of sexual dysfunction as women with natural menopause. HRT cannot alleviate all the symptoms of sexual dysfunction but it is beneficial for vaginal complaints . Counseling and health education in which a positive attitude towards menopause is portrayed is important.

Minor side effects of hormonal replacement therapy in menopausal Thai women.

Objective : To evaluate type and incidence of minor side effects of hormonal replacement therapy (HRT). Design : Cross-sectional, descriptive study. Patients : 114 women, who were follow up at Menopause Clinic in July 2001. Methods: All women were interviewed about their experience in various symptoms possibly related to HRT side effects. The symptoms before and during HRT were recorded. The symptoms that were present only during HRT but not before HRT were considered as side effects. Results : The study showed that breast pain was the most common side effect of both cyclic HRT (40%) and continuous HRT (38.1%) groups; whereas the complaint of weight gain was more pronounced in the estrogen only (31.8%). Conclusion : Although minor side effects of HRT are not life threatening, they may have influence on the compliance of HRT. The incidence of minor side effects of HRT is varied depending on the HRT regimens. However, the symptoms similar to the HRT side effects are already present prior to HRT in a certain number of patients.

Diagnostic laparoscopy and endometriosis.

The prevalence of endometriosis in the population varies according to the study. The purpose of this paper is to determine and evaluate the frequency of endometriosis in patients who underwent diagnostic laparoscopy with various clinical diagnoses and presentations. Medical and laparoscopic surgical records of 856 patients who underwent diagnostic laparoscopy from January 1999 to December 2000 in the Endoscopic Unit, Department of Obstetrics and Gynecology, Siriraj Hospital, are retrospectively evaluated. 661 consecutive cases aged from 17-71 years were recruited for the study. 51.1% were finally diagnosed with endometriosis and the majority were between 20-39 year-old. We found 194 endometriotic cases out of 229 clinically suspected endometriotic cases (84.7%), 50 out of 84 pre-operative chronic pelvic pain cases (59.5%), and 52 out of 132 infertility cases (39.4%). However, no visible pathology was detected in 13 out of 229 clinically suspected endometriotic cases (5.7%). Interestingly, among endometriotic cases in the chronic pelvic pain group, 36 cases (72.0%) had a minimal to mild degree of endometriosis while 14 cases had a moderate to severe degree. For all clinical diagnoses, the frequency of endometriosis in patients with an adnexal mass was found to be significantly higher than that without adnexal mass, 125 /171 cases (73.1%) compared with 181 /368 (49.2%) respectively (p < 0.05). We conclude from this study that the revised ASRM system of classifying endometriosis has limitations and inherent defects. This system does not correlate well with pain. However, at the time of laparoscopy, endometriosis should be staged according to the revised ASRM classification of endometriosis in order to facilitate follow-up and comparison if future surgery is performed. To avoid unnecessary exposure to the attendant risks and the expense of laparoscopy, most diagnostic laparoscopies should be performed selectively. Biopsy is recommended in any clinically suspected endometriosis.

Premature Ovarian Failure (POF): Cytogenetic and SRY analyses.

Premature ovarian failure (POF) is a condition causing amenorrhea, hypoestrogenism and elevated gonadotropins and can be found in 1% of women before the age of 40. There are many causes of POF. One of these is a chromosome abnormality especially of the sex chromosome, the most common of which is 45,X. Translocation between regions on the X and Y chromosome and X chromosome deletions have also been reported. The objectives of this study were to perform chromosome analysis and to look for the SRY gene in the patient with POF. 25 patients with POF attending the Gynecologic Endocrinology Clinic at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, were included in this study. Peripheral blood was collected from the patients for cytogenetic and SRY analyses. There were 4 patients (16%) with identifiable abnormal X chromosomes, which were 45,X/46,XX ; 46,X,i(Xq) ; 46,XX/47XXX and 47,XXX. All patients were SRY negative. POF may be caused by other causes such as auto-immunity, mumps oophoritis etc. Interestingly, this study revealed much higher chromosome abnormalities rate among Thais with POF than has been previously reported elsewhere although those chromosome anomalies are very similar. Chromosome study should be routinely performed as a part of basic laboratory evaluation for all patients with POF. The information obtained will be useful for genetic counseling, planning patient management and family members' decisions in the future.

Assessment of fetal lung maturity by multiple testing with shake test, tap test and OD 650.

Assessment of fetal lung maturity is of great importance in obstetric practice to plan for the future care and proper time for termination of pregnancy. At present, there are many methods used for screening for fetal lung maturity. A good screening test should be simple, easy to perform, rapid, inexpensive and be sensitive and specific. This study was a comparative study of fetal lung maturity assessment by using multiple testing: shake test, tap test and OD 650. These three tests were performed simultaneously and interpreted within 10-15 minutes. The results were compared with lecithin and sphingomyelin ratio (L/S ratio) which was used as the gold standard. L/S ratio > 2 was interpreted as “mature” in this study. Aminotic fluid samples wee obtained from women with uncomplicated pregnancies who underwent amniocentesis for fetal lung maturity testing with consent. All samples were uncontaminated by blood or meconium. The results, analysed from 185 samples studied, showed that the shake test, tap test and OD 650 gave a sensitivity of 79.3%, 87.1%, 76.6% and a specificity of 60.0%, 45.0% and 54.2% respectively, which were not statistically different (P>0.05, Cochran’s test). Screening for maturity using two or more tests gave a sensitivity of 82.7% and a specificity of 55.8% which were also not statistically different when compared with each test. In conclusion, shake test, tap test or OD 650 can be easily used as a simple and sensitive screening method for fetal lung maturity. Multiple testing, performing all three tests simultaneously, did not increase the sensitivity or specificity of the test and is not recommended. The choice of test at a screening method is therefore up to individual preference of depends on facilities available.

Long-term compliance with hormonal replacement therapy: Experience of Siriraj menopause clinic.

A retrospective analysis of women who registered for treatment at Siriraj Menopause Clinic in the year 1995 was performed to assess long-term compliance with hormonal replacement therapy (HRT). There were 217 women who registered that year and all were followed up for the following four years. Of these 217 women, 195 commenced HRT and were divided into two groups. The first group of 1,105 women (natural menopause, N) comprised 25 menopause transition and 80 postmenopause cases. The second one of 91 women (surgical menopause, S) was the group who previously underwent total hysterectomy with bilateral salpingooophorectomy. The average age at first consultation in the N group was 52.1 + 6.5 year which was significantly higher than 46.7 + 7.7 year in the S group (P<0.0001). In the N group, compliance was 61.9% at 1 year and 56.1%, 50.4%, 43.8% at 2,3 and 4 years while in the S group compliance was 74.7% at 1 year and 64.8%, 58.2%, 47.2% at 4 years respectively. Compliance with HRT was not statistically different between both groups (P>0.05). Drop out cases were maximum in the first years in both groups and total drop out cases increased slowly and steadily every year for the next four years. Ages at first consultation of compliant and non compliant women in each group were also not statistically different (P>0.05). Long-term compliance with HRT in this study was comparable with previously reported data. Main reasons for non compliance at 4 years were breast symptoms including breast masses and mastalgia, abnormal vaginal bleeding or irregular menses, weight gain and skin problems including acne, melasma and hair loss. These problems are different from other reports. Factors affecting long-term compliance with HRT should be further studied especially in those women who have undergone a surgical menopause.

Comparison of three methods for DNA extraction from amniotic fluid for fetal sex determination by multiplex polymerase chain reaction (PCR).

The objective of this study was to compare three methods used for amniotic fluid DNA extraction. These methods were: Proteinase K/Phenol-Chloroform, Proteinase K/7.5M Guanidine-HCl and DNAzolา BD Reagent. Ten samples of uncontaminated amniotic obtained by amniocentesis performed in mothers with advanced maternal age for detection of fetal chromosome abnormality were studied. Each sample was divided into three tubes, 1 ml placed in each, and DNA extraction was performed by all three methods. The quality and quantity of DNA extracted by each method were compared by electrophoresis on 3% agarose gel and spectrophotometric study at 260 & 280 nm. The DNA obtained was subsequently used for fetal sex determination by multiplex PCR method. The primers used for multiplex PCR were specific for X and Y chromosomes. Accuracy of fetal sex determination was compared with the results from amniocyte culture and the sex at birth. The results showed that DNA extracted by DNAzolาBD Reagent was 100% accurate when used to determine fetal sex by PCR; eight samples on 1st PCR and the other two on repeat PCR. DNA extracted by Proteinase K/7.5M Guanidine-HCl also yielded 100% accuracy in fetal sex determination; seven samples on 1st PCR, two samples on 2nd PCR and one sample needed 3rd PCR. The Proteinase K/Phenol-Choroform method yielded only 90% accuracy and one sample failed to determine fetal sex after having repeated PCR three times. The extraction method which gave the maximum amount of DNA was the Proteinase K/Phenol-Chloroform one but the failed to give 100% accuracy in determining fetal sex. The method which produced the least protein contamination was DNAzolฎBD Reagent and gave 100% accuracy in determining fetal sex with smallest number of PCR reactions. In conclusion, DNAzolฎBD reagent method is relatively rapid for amniotic fluid DNA extraction with high accuracy for fetal sex determination but when large amount of DNA is also needed for other purposes, Proteinase K/Phenol-Chlorofrom is recommended as the method of choice.

Cesarean section rate and perinatal mortality rate at Siriraj Hospital during 1980-1990.

Cesarean section rates have increased markedly in many centers all over the world in the past 20 years. A retrospective analysis was made using the obstetrics data from one teaching hospital in Bangkok in order to see trends in cesarean section and perinatal mortality during the years 1980-1990. We analysed the annual cesarean section rate, the perinatal mortality rate, and the major indications for cesarean section. Z-test was used to investigate statistical significance. There was a significant increase in the primary cesarean section rate, the repeated cesarean section rate and the total cesarean section rate in the year 1980-1987. After 1987, the rates reached a plateau until December, 1990. Cephalo-pelvic disproportion, breech presentation and fetal distress were the three leading causes of cesarean section in this study. There were significant increase in cephalopelvic disproportion and fetal distress in the second half of the decade compared with the first half. Breech presentation at the time of delivery slightly increased during this time without statistical significance. Perinatal mortality rate decreased significantly from an average of 13.53 between 1980-1984 to 11.12 between 1985-1990. Increasing vaginal birth after cesarean section may be an important means to reduce the cesarean section rate by decreasing the repeated cesarean section rate. This practice has been reposted to lower cesarean section rates in many centers.