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.

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.

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.

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.

Germ cell tumors of the ovary: A review of 644 cases.

This retrospective study reports 644 female patients with germ cell tumors of the ovary treated at Siriraj Hospital over a ten-year period from 1988-1997. The incidence was 38.7% of all ovarian tumors (1665 cases). Of the total, 608 patients (94.4%) had benign cystic teratomas and only 36 patients (5.6%) had malignant tumors. Dysgerminoma was the most common malignant germ cell tumor. Germ cell tumor was the most common malignant ovarian tumor in patients less than 20 years old. The mean age and parity of patients with benign tumor was significantly higher than those with malignant tumors (p<0.01). Benign tumors were often asymptomatic (35%) when the tumors were discovered but those with malignant tumors usually had symptoms and the most common symptoms was a palpable abdominal mass (47.2%). In the cases with benign tumors, more than two-thirds (73.7%) had a tumor less than 10 cm in length, but more than half (66.7%) of the patients with malignant tumors had an intermediate tumor between 11 and 20 cm long. Most of the patients in both groups had a unilateral tumor (p>0.05). Surgical treatment was conservative in 63.8% of patients with benign tumors, while only 30.6% of those with malignant tumors underwent conservative surgery (p<0.05).

Borderline epithelial ovarian tumor: A study of 48 cases.

Borderline epithelial ovarian tumor is a special entity of ovarian tumor. Compared with invasive epithelial ovarian cancer, borderline tumors have a much more favorable prognosis. Several issues remain unclear in the management of patients with borderline ovarian tumor. Objective : To review the clinical features, treatment and survival status of patients with borderline epithelial ovarian tumors. Materials and methods : A retrospective review of the records of 48 patients with borderline epithelial ovarian tumors registered at the Gynaecologic Oncology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University from January 1, 1986 - December 31, 1998 was performed. Results : Ninety percent of the patients had stage I disease. Mucinous cell type was found in 77.1% and serous cell type was found in 22.9%. All the patients received surgery and most of the patients received adjuvant chemotherapy. Mean follow up time was 38.94 months and the 10 - year survival rate was 97.92%. Three patients had recurrence of disease. All patients with recurrence did so within 12 months. Conclusion : The prognosis of patients with borderline epithelial ovarian tumor is good. Conservative surgery should be performed for stage I patients who wish to remain fertile.

Ovarian tumors in children and adolescents: A 10-year review.

This retrospective study reports on 99 young patients (under 20 years) with ovarian tumors treated at Siriraj Hospital over a ten-year period from 1988-1997. The incidence was 5.9% of all ovarian tumors (1,665 cases). Ninety-five patients (96%) were nulliparity. The common presenting symptom was either abdominal mass (42.4%) or abdominal pain (33.3%). More than half of the patients (58.6%) had tumors between 6 and 15 cm in greatest diameter and the bilaterality rate was 12.1%. Fifteen patients (15.2%) had complication of the tumors, 14 of which were torsion. No statistic significant difference in presenting symptom, tumor size, laterality, and complication between benign and malignant tumors was found. Of the total, 77 (77.8%) patients were benign, 18 (18.2%) were malignant and four (4%) were borderline tumors. The frequency of ovarian malignancy correlated inversely with age of the patient (p=0.006). Germ cell, common epithelium, and stromal cell tumors were found in 60.6%, 37.4%, and 2% of patients, respectively. Surgical treatment was conservative in 90.9% and radical in 9.1% of the patients.