The Mediating Effect of Attitudes Towards Senility and Death on the Relationship Between Marital Satisfaction and Depression in Presenile Postmenopausal Women

BACKGROUND: Background: Depression is the most common medical and psychological affliction in presenile postmenopausal women. The aim of the present study was twofold: first, to investigate whether attitudes towards senility mediate the effect of marital satisfaction on depression in presenile postmenopausal women; second, to investigate whether attitudes towards death mediate the effect of marital satisfaction on depression in presenile postmenopausal women. METHODS: One hundred thirty physically active, married female participants in their 50s, who were receiving postmenopausal hormone replacement therapy at Senile Women's Clinic, Jeju National University Hospital, were recruited. To assess the women's mental health and outlooks on life, the Korean version of Beck's Depression Inventory, the Korean version of the attitudes towards ageing questionnaire, the Korean version of the attitudes towards death questionnaire, and the Korean marital satisfaction scale were used. RESULTS: The effect of marital satisfaction on depression in presenile postmenopausal women was partially mediated by attitudes towards senility. Conversely, the effect of marital satisfaction on depression in presenile postmenopausal women was not mediated by attitudes towards death. CONCLUSION: In presenile postmenopausal women, apprehensions concerning senility are more influential than those concerning death in the onset of depression. Therefore, medical management and/or psychological counseling for presenile postmenopausal women with depression, should take into account their attitudes towards senility.

A Case of Trisomy 8 Mosaicism in a Patient with Secondary Amnorreha without Abnormal Phenotype

Constitutional trisomy 8 mosaicism (CT8M) is a relatively rare aneuploidy in humans with characteristic phenotypes including typical craniofacial feature (such as deformed skull, prominent forehead, low-set and/or dysplastic ears), skeletal malformation, cardiac anomaly, renal malformation, cryptochidism, varying degree of developemental delay. Due to the extremely variable phenotypic and cytogenetic expression, CT8M has gone undiagnosed in certain patients. We report a 28-year-old women with secondary amenorreha without characteristic CT8M phenotype. Chromosomal analysis showed a CT8M (47,XX,+8[9]/46,XX[41]).

The medicolegal understanding regarding fetocide in the criminal law and artificial termination in the mother and child health law / 대한산부인과학회지

Recently, in our society, there have been a lot of talks about fetocide and artificial abortion. I suppose it would be natural in a way. Because the very problem of fetocide and artificial abortion has been always there in our society and various concerns about it still hover above our lives. Fetocide in the criminal law, by legal definition, means the artificial evacuation of growing fetus from mother's uterus or killing the fetus in the mother's uterus. Meanwhile, artificial termination in the mother and child health law, by legal definition, means artificial evacuation of growing fetus and gestational by-products through medical procedure within such a early period in fetal life unable to survive outside the mother's uterus. A couple of jurisprudential reasoning about fetocide and artificial abortion could be possibly constituted in accordance with the legal point of view. But, in the scene of medical practice of Obstetrics and Gynecology, there would be very little difference in terms of criminal charges. It is concluded that both occasions of any artificial abortion with no allowable reasons and any artificial abortion with allowable reasons committed in the period beyond 24 weeks of gestation are to be punished by the current criminal law.

A case of microinvasive Paget's disease of the vulva: Treatment of positive resection margin with topical 5-FU cream application / 대한산부인과학회지

Extramammary Paget's disease of the vulva is a rare lesion that accounts for 1~2% of vulvar neoplasms. Paget's disease often has a microscopic extension beyond the gross lesion and shows a multifocal distribution. Positive resection margin is common. We applied 5-FU cream on the lesion who had a positive resection margin. There was no residual lesion on multiple punch biopsies after 5-FU cream treatment three months later. And there has been no evidence of disease recurrence in the 12-month follow-up period. We experienced a case of effective treatment with 5-FU cream in microinvasive Paget's disease of the vulva with positive resection margin. We present it with a brief review of literatures.

The medicolegal understanding regarding sexual violence / 대한산부인과학회지

Sexual violence, by definition, means all kinds of the physical, emotional, or linguistic violence by means of sex on which one would never agree. In a broad sense, sexual violence could include sexual assault, molestation (also referred to as sexual abuse), and sexual harassment. Sexual assault is a substitute for rape used in media reports. Rape is an coerced sexual intercourse in which a man is putting his penis inside a woman's vagina by means of an act of violence and intimidation and a heinous crime which infringe on human rights of sexual self-determination, and freedom and tranquility of sexual life. Psychologically, it is important to be aware that rape is not a sexual behavior in common sense. It should be treated as an event in which one person violate another by means of sex. Many a serious rape is liable to be committed from the impure motive of sadistic ostentation of one' power and retributive exhibition of one's anger. The criminal object of rape is women and girls. Previously, as prescribed by law, interpretation of the law restricted the object of the crime to biological and genetical female who also is not rapist's wedded wife. But, the latest judicial precedent appreciated a person who is rapist's wedded wife as the object of the crime. Considering previous judicial precedents and the tendency of juridical interpretation on the minors of transgender, even a transgender female underwent sex exchange operation could be legally appreciated as the object of the crime. So, therefore, gynecologist who would initially confront rape victim in the field of medical practice should carry out one's medical and legal obligation, irrespective of whether or not the victim would be a biological and genetical female or a rapist's wedded wife or a transgender female underwent sex exchange operation. Especially, gynecologist should not judge whether rape is committed or not only by external wound. And, even if the victim and legal guardians would not want to accuse rapist on charges of rape at the moment, gynecologist should collect all the criminal evidences just in case an accusatorial procedure would be presented later on. Successful prosecution of rapist would be dependent upon the completion of the detailed forensic examination. Because of the legal ramifications of rape, consent should be obtained from the victim before taking the history, performing the physical examination, and collecting the criminal evidence. Many rape survivors would not inform their gynecologist of the assault voluntarily, unless they are directly asked. So, therefore, on getting a medical history, gynecologist should routinely ask their patients a question, "Has anyone ever coerced you to have sexual relations?". Actually, rape is severe and complex form of trauma which could bring about an excruciating damage on physical, psychological, and sexual health and, thereupon, might have an impact on the victim for the rest of one's days.

Medical record and privacy of patients / 대한산부인과학회지

Making out medical record is one of the fundamental obligations of doctors in medical service. Primarily, the meaning of medical record is the logical basis to guarantee consistent medical practice by writing out the detailed process, which could make the doctors remember the items of what they have done for their patients. But, nowadays when the medical service is highly specialized and differentiated, it also means not only the important method of communication amongst specialized medical divisions but also legal basis for adjudicating the appropriateness of medical practice at the court. In the process of medical practice, it would be inevitable for personal information, health information and genetic information to be disclosed. On the one hand, doctors meet the legal and ethical obligation to protect the right of privacy of their patients, on the other hand, they bear the legal obligation to observe the rule for the patients' right to know and right of self determination for private information. So, therefore, even if doctors are to provide medical record by the legal provisions, they should inform the patient of the reality and maximum careful attention should be paid in order to minimize the extent of exposure of patients' personal information, health information and genetic information.

The effect of oral contraceptive pre-treatment in controlled ovarian hyperstimulation using GnRH antagonist on IVF-ET outcome / 대한산부인과학회지

OBJECTIVE: Recent reports have demonstrated that GnRH antagonists can be successfully used in controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). In these antagonist stimulation cycles, oral contraceptive (OC) pretreatment was used to schedule COH. This study was performed to evaluate the effect of OC pretreatment before COH in the antagonist cycles according to the duration of OC administration in infertile patients undergoing IVF-ET. METHODS: Prospective trial was performed on a total 85 IVF cycles carried out on 85 infertile patients with tubal factor only. Eighty-five patients was allocated randomly to the short term OC user (14-21 days), long term OC user (>or=22 days) and Non-user of OC. In all patients, COH was carried out using GnRH antagonist and recombinant FSH (rFSH). RESULTS: No differences among the three groups were found in numbers of oocytes retrieved, mature oocytes, fertilized oocytes, embryos grade I/II, transferred embryos and clinical pregnancy rate. There were also no differences in total dose and duration of rFSH used for COH among three groups. CONCLUSION: Oral contraceptive pretreatment can be used successfully to schedule patients before COH in GnRH antagonist cycles. The OCs can be administered for extended period as necessary for cycle timing. However OC pretreatment in antagonists cycles does not offer any advantage in COH and pregnancy outcome.

A Case Report of Heterotopic Pregnancy after IVF-ET / 대한불임학회지

Heterotopic pregnancy is named when an extrauterine (ectopic) pregnancy coexists with an intrauterine pregnancy simultaneously by many causes such as PID (pelvic inflammatory disease), endometriosis, IUD (intrauterine device), previous pelvic surgery and others. This is very rare in general population, with a range of occurrence estimated between 1:7963 and 1:30000. But recently the incidence has increased as the uses of ARTs (assisted reproductive technologies) including ovulation induction, IVF-ET (in-vitro fertilization and embryo transfer) and GIFT (gamete intrafallopian transfer) increase. Because this has high maternal morbidity, mortality and fetal loss, early diagnosis and proper management is very important. We report a case of heterotopic pregnancy following IVF-ET with a brief review.

A Case of Primary Peritoneal Serous Papillary Carcinoma / 대한산부인과학회지

Primary Peritoneal Serous Papillary Carcinoma has a diffuse involvement of peritoneum in the absence of an obvious primary site and is very rare. It is histologically identical to ovarian serous papillay carcinoma but involves the ovarian surface mimimally, or spare the ovaries. Clinically it is impossible to differentiate with other tumor originated from peritoneum and ovarian carcinoma because of the similarity of clinical presentation and course. Primary Peritoneal Serous Papillary Carcinoma was first described by Swerdlow in 1959 and then has been very rarely reported in literatures. A few cases were reported in Korea. We have experienced a case of Primary Peritoneal Serous Papillary Carcinoma and report this case with a brief review of concerned literatures.

Effects of Pioglitazone on Insulin Sensitivity, Ovarian Function and Intraovarian Stromal Blood Flow in Women with Polycystic Ovary Syndrome / 대한불임학회지

OBJECTIVE: This study was performed to investigate the effects of pioglitazone, an insulin sensitizing agent, on insulin resistance, ovarian function and intraovarian stromal blood flow in patients with polycystic ovarian syndrome (PCOS). MATERIAL AND METHODS: Thirty patients with PCOS, aged 18~34 years, were recruited. Criteria for diagnosis of PCOS were as defined in 2003 Rotterdam consensus. They were treated for 6 months with pioglitazone at a dose of 30 mg/day orally. The hormonal blood profile, fasting serum glucose levels, a glycemic response to 75 g oral glucose tolerance test (OGTT), and an ovarian stromal artery (OSA) blood flow were assessed at baseline and after 6 months of treatment. RESULTS: Eighteen (60.0%) of 30 patients treated with pioglitazone demonstrated a spontaneous ovulation After pioglitazone treatment, fasting insulin concentrations, serum glucose levels after 75 g OGTT significantly decreased (p=0.001, p=0.04, respectively), and fasting glucose to insulin (G/I) ratio significantly increased (p<0.001). The pioglitazone treatment induced a significant reduction in serum LH, testosterone (T) and free T levels (p<0.001, p=0.02, p=0.002, respectively). The resistance index (RI) values of OSA significantly increased after treatment (p<0.001). In analyzing pioglitazone-treated patients according to their body mass index (BMI), nonobese group as well as obese group showed a significant improvement in fasting G/I ratio (p<0.01). The pioglitazone treatment induced a significant reduction in serum LH and free T levels in nonobese group (p<0.001, p<0.05, respectively) as well as obese group (p=0.001, p<0.05, respectively). The RI values of OSA significantly increased in both nonobese and obese groups after pioglitazone treatment (p<0.001, p=0.003, respectively). CONCLUSIONS: Pioglitazone could ameliorate the glycoinsulinemic metabolism, and this beneficial effects of this drug could improve the endocrine-reproductive condition associated with the decrease of ovarian stromal artery blood flow, in both nonobese and obese patients with PCOS.

Efficacy of controlled ovarian hyperstimulation using GnRH antagonist in women with polycystic ovary syndrome undergoing IVF-ET / 대한산부인과학회지

OBJECTIVE: GnRH antagonist has been recently developed and has provided a new treatment option for controlled ovarian hyperstimulation (COH). However, the use of GnRH antagonist (GnRH-ant) has been hesitated in women with polycystic ovary syndrome (PCOS) due to their high levels of tonic luteinizing hormone (LH). This study was performed to evaluate the efficacy of 2 kinds of GnRH-ant multidose protocols (MDPs) in infertile women with PCOS undergoing IVF-ET, compared with standard GnRH agonist (GnRH-a) luteal long protocol (LP). METHODS: Sixty-five patients with PCOS, aged 24-38 years were recruited for this prospective study and they were randomized to undergo GnRH-ant MDP during early and late follicular phase (GnRH-ant MDPEL) (group 1), GnRH-ant MDP during late follicular phase (GnRH-ant MDPL) (group 2), or GnRH-a luteal LP (group 3). All of the subjects were pretreated with low dose monophasic oral contraceptives (OCs) and they were administered recombinant FSH for ovarian stimulation. RESULTS: There were no differences in serum concentrations of progesterone and endometrial thickness on the day of hCG injection among three groups but serum concentrations of estrogen are higher in group 3 (GnRH-a luteal LP) than other groups. Total dose and duration of rFSH used for COH were significantly higher in group 3 than those in group 1 or 2. Number of retrieved oocytes, grade I/II embryos, fertilized oocytes were significantly higher in group 3 than those in group 2 but there were no differences in any parameters including IVF results between group 1 and 3. No difference in ongoing pregnancy rate was found among 3 groups. CONCLUSION: The use of the GnRH-ant, especially during early and late stimulation period (GnRH-ant MDPEL) is as effective as GnRH-a LP and might be considered more advantageous because of the short-term and small dose application, and therefore GnRH-ant MDPEL could be cheaper alternative in COH for PCOS women undergoing IVF-ET.

The efficacy of oral contraceptive pre-treatment in controlled ovarian hyperstimulation using a GnRH antagonist in low responders / 대한산부인과학회지

OBJECTIVE: This study was performed to evaluate the efficacy of GnRH antagonist multidose protocol (GnRH-ant MDP) with or without oral contraceptive (OC) pretreatment in low responders undergoing IVF-ET, compared with standard GnRH agonist (GnRH-a) lowdose long protocol (LP). METHODS: Eighty-two patients, aged 28-42 years who were defined as low responders were recruited for this prospective study and they were randomized to undergo GnRH-ant MDP after OC pretreatment (group 1) or GnRH-ant MDP without OC pretreatment (group 2) or GnRH-a luteal lowdose LP (group 3). All of the subjects were administered recombinant human FSH (rhFSH) for ovarian stimulation. RESULTS: Patients' characteristics were comparable among three groups. Total dose and duration of rhFSH used for COH were significantly higher in group 3 than those in group 1 or 2. The number of mature oocytes, fertilization rate and the number of grade I, II embryos were significantly lower in group 2 than those in other groups. The clinical pregnancy rate seemed to be lower in group 2 but the difference did not achieve statistical significance. There were also no differences in the miscarriage rate and multiple pregnancy rate among three groups. CONCLUSION: This study demonstrates that GnRH-ant MDP with OC pretreatment is as effective as GnRH-a lowdose LP and might be considered more advantageous because of the short-term and small dose application in low responders.

Perinatal Outcome in Relation to the Latency of Delivery in Severe Preeclampsia before 32 Weeks of Gestation / 대한주산의학회잡지

OBJECTIVE: To study the differences in the pregnancy outcomes of severe preeclampsia before 32 weeks of gestation in relation to the latency between admission and delivery. METHODS: We reviewed medical records of 89 pregnant women who were managed in Samsung Medical Center because of severe preeclampsia before 32 weeks of gestation between January 1996 and February 2004. We studied the differences in the management and the neonatal outcomes between the immediate delivery group (admission to delivery 2 days). We excluded maternal renal disease, chronic hypertension, multiple pregnancies, diabetes and placenta previa from this study. RESULTS: 40 women were included in the immediate delivery group and 49 women in the expectant management group. Antenatal corticosteroid was given pregnant women in the expectant management group (89.8% vs. 52.5%, p<0.0001). There was no significant difference in the occurrence of small for gestational age- and prematurity-related complications including neonatal mortality. There was significantly less respiratory distress syndrome in the expectant management group (46.9% vs. 62.5%, p=0.0315). However this difference disappeared when the adjustment was made to the gestational age at delivery (p=0.223). CONCLUSION: The latency period does not seem to alter the neonatal prognosis in severe preeclampsia before 32 weeks of gestation but the gestational age at the delivery, a reflection of the severity of the preeclampsia, seems to be the single most important factor for the occurrence of neonatal respiratory distress syndrome.

Maternal and Fetal Outcomes according to the Latency Period in Preterm Premature Rupture of Membrane / 대한주산의학회잡지

OBJECTIVE: To evaluate the clinical characteristics and perinatal outcomes in relation to the latency period after preterm premature rupture of membrane (PPROM). METHODS: We analyzed retrospectively the 223 pregnant women with PPROM who delivered before 34 weeks of gestation in Samsung Seoul Hospital from January 1996 to October 2003. The study population was divided into six groups according to the larency from membrane rupture and delivery (group I: shorter than 6 hours, group II: 6~48 hours, group III: 2~4 days, group IV: 4~7 days, group V: 7~12 days, group VI: beyond 12 days). RESULTS: The mean gestational age (GA) at rupture was 29.6+/-2.6 weeks and the mean GA at delivery was 30.6+/-2.4 weeks. The median latency was 102 hours and 67% of patients delivered within 7 days. The latency was prolonged with GA at rupture before 30 weeks and used of tocolytics. After adjustment of GA at delivery, pathologic chorioamnionitis occurred more frequently in group V than group I. Respiratory distress syndrome occurred less frequently in group II and group IV than group I. Neonatal mortality rate was highest in group I, but the other neonatal morbidities were not significant differences. CONCLUSION: In PPROM with delivery before 34 weeks, prolongation of the latency longer than 6 hours seems to be beneficial for reducing neonatal RDS and mortality, but infectious morbidity seems to increase when the latency was prolonged longer than 7 days without any benefits for perinatal outcomes.

Clinical profiles of 10 cases of ovarian malignant mixed mullerian tumor / 대한산부인과학회잡지

Malignant mixed mullerian tumors (MMMT) of the ovary are rare, constituting less than 1% of all primary ovarian tumors. Histologically, tumors include malignant epithelial and sarcomatous elements. MMMT of the ovary is a highly aggressive and rapidly progressive tumor with a poor long-term prognosis. The survival rate is very low inspite of surgery, chemotherapy and radiotherapy. The prognostic factors and optimal treatments for this tumor are still controversial because of its rarity. We experienced ten cases of malignant mixed mullerian tumors of the ovary and report our experiences with a brief review of literature.

Correlation between High Risk Human Papillomavirus Infection and p53 Protein Overexpression in Adenocarcinoma of Cervix / 대한산부인과학회잡지

OBJECTIVE: The aim of the present study was to analyze the relation between p53 mutation and cervical adenocarcinoma without HPV infection. METHODS: From 1998 to 2002, 54 patients were diagnosed with cervical adenocarcinoma and underwent radical hysterectomy at Seoul National University Hospital. Of them, 50 patients were available for review of medical records and histologic examination. Using ABC method, we performed immunohistochemical staining. If there is 10% or more of staining positive, it was read positive. And we used HPVDNAChip for detection of HPV. RESULTS: Of the 50 patients, 45 (90.0%) patients were positive for high risk HPV and 4 patients (8.0%) were p53 positive. In the patients with negative for p53, there were significantly more patient with HPV positive (p=0.04). Advanced stage of cervical adenocarcinoma was related to high rate of positivity of p53, but it was not statistically significant. CONCLUSION: In patients who diagnosed cervical adenocarcinoma without HPV infection, there were over expression of p53. This suggests that abnormality of p53 may be related to pathogenisis of cervical adenocarcinoma without HPV infection.

Expression of Ids in Preimplantation Mouse Embryos / 대한불임학회지

OBJECTIVE: The Id family of helix-loop-helix proteins are thought to affect the balance between cell growth and differentiation by negatively regulating the function of basic-helix-loop-helix (bHLH) transcriptional factors. The aim of this study was to investigate the expression pattern of Ids (Id-1,-2,-3, and -4) in preimplantation mouse embryos at mRNA and protein levels. METHODS: Oocytes and preimplantation embryos were collected from reproductive organs of female ICR mice following superovulation. RT-PCR was performed to investigate the mRNA expression patterns of Id genes and their protein were localized by immunofluorescence analysis. RESULTS: Id-1 and Id-3 mRNAs were strongly expressed at the germinal vesicle (GV) oocyte and the blastocyst stages. Id-2 mRNA was expressed throughout preimplantation embryo development, but Id-4 was not expressed. Immunofluorescence showed that Id-1 and Id-2 were predominantly localized in cytoplasmic region, but the immunofluorescence signal of Id-3 was weak throughout preimplantation embryo development. CONCLUSION: These data show for the first time that Ids are expressed in preimplantation mouse embryos and suggest that Ids may play an important role in early preimplantation embryo development and uterine physiological changes.

Effect of Metformin Treatment and Insulin Resistance in Patients with Polycystic Ovary Syndrome / 대한산부인과학회잡지

OBJECTIVE: This study was performed to investigate the effect of metformin treatment and insulin resistance in the patients with polycystic ovary syndrome. METHODS: Twenty three patients with polycystic ovary syndrome were included at Seoul National University Hospital from September 2001 to September 2003. Metformin was administered at daily 1,500 mg for 3 months to these patients. Then restoration of regular menstruation or recovery of ovulation was evaluated and insulin resistance was compared between the responder and the non-responder before and after metformin treatment. RESULTS: Eleven patients (47.8%) showed a significant improvement in menstrual or ovulation cyclicity whereas twelve patients had no change. There was no statistically significant difference in the insulin resistance between the responder and the non-responder before and after metformin treatment. CONCLUSION: In non-obese patients with polycystic ovary syndrome, metformin treatment seems to be effective to improvement of menstrual or ovulation cyclicity irrespective of insulin resistance expressed as glucose-to- insulin ratio and HOMA.

Factor VIII Gene Mutations in Korean Patients with Hemophilia A / 대한산부인과학회잡지

OBJECTIVE: To identify mutations within the factor VIII gene in Korean patients with severe hemophilia A. DESIGN: A laboratory analysis. METHODS: We systematically sequenced the promoter, all exons and splice junctions of factor VIII gene in 23 unrelated Korean patients with severe hemophilia A. Patients with factor VIII gene inversion were excluded. RESULTS: Twelve patients (52.2%) showed a point mutation, among which 6 were nonsense mutations and the other 6 were missense mutations. A large deletion was found in 6 (26.1%) patients, a small deletion in 2 (8.7%), a small insertion in one patient. Two patients had compound mutations: one patient had two missense mutations, and the other had a missense mutation and 4 bp insertion. Ten (43.5%) out of 23 mutations found are novel. CONCLUSION: Mutations within the factor VIII gene found in Korean patients with moderate to severe hemophilia A are diverse as expected. And we have found 10 novel mutations. Our results can help understanding the molecular pathology of hemophilia A.

A Case of Reconstruction of Utero-neovaginal Continuity / 대한산부인과학회잡지

Vaginal and cervical agenesis is an uncommon Mullerian anomaly. Total hysterectomy and vaginoplasty remains the classical treatment of this malformation. We present a case of reconstruction of utero-neovaginal continuity in the patient with normal functioning uterus and previously constructed neovagina by McIndoe method. She experienced two episodes of withdrawal bleeding during 2 months after surgery and fully satisfied with the results.