One-year assessment of women receiving sub-dermal contraceptive implant at Siriraj Family Planning Clinic.

BACKGROUND: The single-rod Implantable contraceptive method, called 'Implanon', has been introduced for use in Thailand since the 1990s. The outstanding attribute was that it requires only a few minutes for insertion and removal as it has only one capsule. The single-rod implant was used in women at Siriraj Hospital in 2006. The present study looked at characteristics of women, complications of insertion and removal, menstrual events that occurred to women during one year of use and reason for removal of the method. MATERIAL AND METHOD: This was a retrospective clinic based study. All women's record files were examined at Siriraj Hospital's Family Planning Clinic. There were 166 women enrolled to undergo this method, and only 89 women (54.6%) came back for the one-year follow-up visit. Women's accounts on irregularity of menses, complaints during method used and reason for discontinuation, pregnancy and body weight change were assessed. RESULTS: Most women (68%) using the implant contraceptive method were 29 years of age with 74% of vocational or lower education. Their BMI was 22.66 +/- 4.06 Insertion time was about 1 minute with no difficulty or complication. Of those women, 40.4% of them considered having regular menstrual cycle and 30.3% had regular menstrual flow for a few months alternately with no menses for a few months. Prolonged menstrual bleeding was the most complaint in this group of women. Amenorrhoea was also reported. Vertigo had occurred to some women without reported medication. One woman asked for the removal of the method due to pain at the implanted site after 8 months of use. Removal time was around 2-3 minutes. There was no pregnancy that occurred in the course of one year of use. CONCLUSION: Of 89 women using the implant contraceptive method, menstrual irregularity was the important issue that women complained about. However, the removal of the method in one woman was due to the pain at the implanted site. There was no difficulty or complications in insertion or removal of the implant. Close counseling about side effects of the method is emphasized during use to maintain long-term use or until completion of the duration of the device.

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.

The comparative study of different contraceptive methods between copper T 380A and norplant 6, Siriraj experience.

Objective: To evaluate and study the demographic and clinical profile among the users of these 2 different contraceptive methods, to assess the continuation rates of these 2 methods as well as the frequency of Pap smear screening plus the resultsof Pap smears in each contraceptive method. Methods: This was a case note-based study in which the data were transferred to a standardized pre-tested proforma. Results: During 1 January - 31 December 2001 There were 162 Copper T 380 A users and 307 Norplant 6 users. The age group of IUD users were found higher than Norplant-6 users with a statistical difference. The continuation rates after 5 years were 39.5% for copper T 380 A and 11.4% for Norplant users. The frequency of Pap smear screening as well as the follow up rate was found much higher in copper T 380 A. The results of Pap smear of these two groups using long-acting contraception were statistically different : IUD users had a higher infection rate but Norplant users had higher abnormal cells. After treatment all users return to normal Pap smear. Conclusion: This contraceptive study was conducted in 2001. The continuation rate for copper T 380 A was significantly higher than Norplant 6 and encouraged the participants to have Pap smear screening as well as keeping the appointment for follow up. The report of Pap smear screening was found abnormally higher in the Norplant users. Actinomyces infection was commonly found with copper T 380 A.

Health check-up program for pre/postmenopausal women at Siriraj Menopause Clinic.

OBJECTIVE: To determine the general health status of pre/postmenopausal women attending the menopause clinic. STUDY DESIGN: Retrospective descriptive study. SETTING: Siriraj Menopause Clinic, Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University. Study population: Pre/postmenopausal women (i) presumed to have no medical disease (no disease group) or (ii) with unknown status of medical disease (no record group) and undergoing health check-up program at the time of registration without prior hormone therapy. MATERIAL AND METHOD: Medical records of new patients registering at the menopause clinic from January 1999 to December 2005 were reviewed. RESULTS: Among 1,020 patients undergoing health check-up program, there were 366 patients in the no disease group. They had abnormal health parameters listing by frequency of prevalence including hypercholesterolemia (62.3%), suboptimal blood pressure (49.3%), overweight to obese (30.2%), suboptimal fasting blood sugar (2 7.9%), hypertriglyceridemia (21.3%), abnormal liver function tests (5.4-6.9%), and abnormal kidney function tests (0.5%). The prevalence of dyslipidemia was statistically higher in the no record group compared to the no disease group; such abnormal parameters included hypercholesterolemia (> or =200 ml/dL), high blood level of low density lipoprotein cholesterol (LDL-C > or = 130 mg/dL), and high ratio between LDL-C and high density lipoprotein cholesterol (LDL-C/HDL-C ratio >3). Osteoporosis was found in 6.6% of the patients. Abnormal mammographic findings that needed close follow-up or breast biopsy were found in 13.5%. Twelve patients had breast biopsy and none had breast cancer. CONCLUSION: Abnormal health parameters are common in pre/postmenopausal women presumed to have no medical disease. The similar or even worse findings are also found in those whose status of medical diseases was unknown. Therefore, a routine health screening program, especially for metabolic diseases, should be offered to pre/postmenopausal women regardless of their medical history.

Serum follicle stimulating hormone and estradiol in peri/postmenopausal women attending Siriraj Menopause Clinic: a retrospective study.

OBJECTIVES: To determine serum levels of Follicle Stimulating Hormone (FSH) and Estradiol (E) in peri/postmenopausal women attending the menopause clinic. STUDY DESIGN: Retrospective descriptive study. SETTING: Siriraj Menopause Clinic, Gynecologic Endocrinology Unit, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. Study population: Peri/postmenopausal women attending Siriraj Menopause Clinic from January 1994 to December 2003. MATERIAL AND METHOD: Medical records of women who had a blood test for FSH and/or E2 prior to hormonal therapy were reviewed. RESULTS: During a 10 year period, there were 116 eligible patients who could be classified into perimenopausal (31 cases), natural postmenopausal (43 cases), and surgical postmenopausal (32 cases) groups. Age at registration of perimenopausal (47.87 +/- 4.38 yr) and surgical postmenopausal (48.06 +/- 6.49 yr) groups were younger than that of the natural postmenopausal group (55.74 +/- 6.80 yr). The perimenopausal group, who still had regular menstruation, was the youngest. The average FSH level of 60.46 +/- 33.15 mIU/mL was not different among groups. The estradiol level of perimenopausal (79.05 +/- 83.62 pg/mL) and surgical postmenopausal (63.05 +/- 136.39 pg/mL) groups were significantly higher than that of natural postmenopausal (25.05 +/- 37.663 pg/mL) group (p = 0.001). Serum level of FSH or E2 was not correlated with age or years since menopause. There was significant but minimal negative correlation between serum levels of FSH and E2. CONCLUSION: Serum FSH and/or E2 levels are not accurate enough by themselves to rule in or rule out perimenopause. The authors suggested that clinicians should diagnose perimenopause based on menstrual history and age, without relying on laboratory testing.

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.

Pain during endometrial sampling between menstrual regulator and standard uterine curette.

This study was designed to compare the level of pain of patients during endometrial sampling, using a menstrual regulator and a standard uterine curette. A randomized single-blind clinical trial was conducted on eighty women who had abnormal uterine bleeding and needed diagnostic fractional curettage at the Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital. They were randomly assigned to two groups. The uterine curettage was performed using a menstrual regulator in the first group and a standard curette in the second group. The pain scores before, during and after the curettage procedure were determined by a visual analogue scale. The time for the procedure was observed and the tissue was sent for pathological evaluation. The median pain scores during and 30 minutes after the procedure were lower in the menstrual regulator group compared to those in the standard curette group (p<0.05). The time in the menstrual regulator group was shorter (p<0.05) and the quality of tissue for diagnosis was better (p<0.05) than in the standard curette group. No serious complications were observed between both groups. Using a menstrual regulator for endometrial sampling can significantly reduce the pain, is easier to perform and yields better tissue tissue quality compared to the standard curette.

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.

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.

Venous thromboembolism and combined oral contraception in Thai women.

Hospital-based case-control study risk of venous thromboembolism (VTE) associated with combined oral contraceptives (OC) in Thai women aged 20-44 years was 7.6. Body mass index (BMI) of cases were significantly higher than controls. The risk of VTE in women having BMI more than 25 kg/m2 was 5.8. Cigarette smoking and alcoholic used did not the risk of VTE in OC user. The OC prevalence in this study in cases and controls were 39.5% and 7.9% respectively. All combined pills composed of 0.05 mg. Or less estrogen and second generation progestogen. This study suggested that the prescription of combined oral contraception to Thai overweight women should be avoided because it increased the risk of venous thromboembolism by two risk factors.

Blood loss in placental delivery between cord traction and manual removal technique during cesarean section.

A randomized clinical trial was carried out to compare the amount of blood loss in placental delivery between cord traction and manual removal during cesarean section. The subjects were 30 singleton pregnant women without complications who underwent cesarean section. Each women had her hemoglobin concentration measured in a peripheral blood sample. Swabs, used for collecting blood loss in placental delivery, were placed in Drabkin’s solution. The total volume and hemoglobin concentration of this solution were measured. Then the blood loss in placental delivery was calculated. Result : amount of blood loss in the cord traction group was 75.5 + 41.5 ml while in the manual removal group it was 134.2 + 77.2 ml. There was a significant difference (P = 0.017). Conclusion: blood loss in placental delivery during cesarean section by cord traction was less than by manual removal. Nevertheless the difference was small, so it may not have clinical importance.

A study of amphetamine users in vocational school boy.

In Thailand, amphetamine locally called “YAMAH” are wrongly used as stimulants. They are widely available among teenagers in vocational schools. In a urinary amphetamine test conducted on three hundred and fifty vocational students aged 18-20 years 13.7% proved positive. Significantly half of the students testing positive were aged only 18 years, maybe because, being younger they are easily led which might have caused by their own inexperienced behavior. It was also found that 42.9% of these students had sex-related diseases, though most had sexual intercourse with their girl friends and only a few with prostitutes. On comparing the sexual histories, we found 62.5% of the positive group always used condom during sexual intercourse, while only 19.4% in the negative group did, a marked statistical difference. On proving deeper with the students test up positive we found that themselves male and female, are agents for the “YAMAH” are family problems and friends. All students realize the danger “YAMAH” poses to their health and the waste of money it causes. Yet, they would be able to stop taking “YAMAH” only if it were not still available in their own schools.

Basal body temperature chart as a guide for donor insemination.

The use of BBT in a single donor insemination and the conception rate according to cycle day was studied. For 107 such cycles, inseminations were performed on day 0 in 21.5% of cycles, on days-1,+1 and –2 in 17.8%, 16.8% and 13.1% respectively. The overall pregnancy rate achieved was 44%. The success rate per cycle was 15%, and the highest success rates were obtained on day 0 (43.7%) and day –1 (31.2%). No pregnancies occurred when insemination was done before day -3 and beyond day +1. In conclusion BBT provides a reasonable guide to the 2-to 3-day period on either side of the nadir in donor insemination.

Molar pregnancy at Siriraj Hospital.

The analytic study of 132 patients with molar pregnancies at the Department of Obstetrics & Gynaecology, Siriraj Hospital during 1984-1987 was carried out in order to find out the clinical features, therapeutic interventions, malignancy change and the effect of chemoprophylaxia. There were 132 patients diagnosed as molar pregnancy which makes the prevalence of 1.82 cases per 1,000 pregnancies or 1.96 cases per 1,000 deliveries. Over half of these patients had uterine size of greater than 16 weeks gestation. The uterus was larger than date encountered in 31.8%. The theca lutein cysts with the diameter of larger than 6 cm were encountered in 10.6%. Associated hypertension was encountered in 25.4% while anemia was in 65.2%. Serum thyroxin level of over 18 gm% was found in 22.4% of patients. Malignancy change or persistent trophoblastic disease was found in 23.8% but without significant difference among high and low risk groups. Chemoprophylaxis did not reduce the rate of malignancy change in high risk group. The malignancy change was frequently encountered during the first year post evacuation (93.8%) and became less (6.2%) during the second year.