Black women with postmenopausal bleeding have lower prevalence of endometrial cancer than other ethnic groups.

Objectives: Modern medical practice strives for a personalized approach to patient care. The evidence regarding the prevalence of endometrial cancer in various ethnic groups is scarce and conflicting. This study was conducted to determine this prevalence in postmenopausal bleeding (PMB) women. Methods: Data for 1995 women attending PMB clinics over a 4-year period were prospectively collected. Women were grouped according to self-assigned ethnicity into 'White', 'Black', 'South Asian' and 'Others', and according to investigation results into group 1 (benign findings) and group 2 (hyperplasia or cancer). Results: The adjusted odds ratio (95% confidence interval) for Black ethnicity was 0.35 (0.17-72; p = 0.001). This means that Black women had 65% (28-83%) less odds for developing endometrial hyperplasia and cancer compared to White women, independent of other predictors. Compared to White ethnicity, women in all ethnic groups were significantly younger at presentation with PMB, had shorter duration since last menstrual period, and were less likely to be diabetic (p < 0.001). Conclusion: This study found significantly lower prevalence of endometrial cancer in the Black race in a population of PMB women, a finding that cannot be readily explained by other known risk factors. Further research is warranted to confirm the results and explore the underlying etiology.

Endometrial pathology in recurrent postmenopausal bleeding: observational study of 385 women.

OBJECTIVES: Women with recurrent postmenopausal bleeding (PMB) are considered as being at higher risk for endometrial hyperplasia and cancer, and guidelines suggest offering hysterectomy in unexplained cases with repeated negative investigations. This study aims to determine the prevalence of endometrial pathology in women referred with recurrent PMB to help inform clinical practice. METHODS: This was an observational study of prospectively collected data over a 5-year period, including 1902 women referred to the PMB clinic. Women were classified into two groups: those with a single referral episode (n = 1517, 79.8%), and women with multiple referrals because of recurrent PMB (n = 385, 20.2%). RESULTS: The prevalence of endometrial hyperplasia or cancer was 32 (8.3%) in women with multiple referrals and 159 (10.5%) in those with a single referral (p = 0.21). The prevalence of benign polyps was 80 (20.8%) and 214 (14.1%) in the two groups, respectively (p = 0.002). On comparing to women with a single referral, the odds ratio (95% confidence interval) for women with multiple referrals because of recurrent PMB to have endometrial polyps was 1.6 (1.2-2.1). CONCLUSION: Women with recurrent PMB had a higher prevalence of endometrial polyps, rather than hyperplasia or cancer, when compared with those with a single referral. Hysteroscopy may be warranted as the first-line investigation, if PMB recurs, to enable polyp diagnosis.

Predictors of malignancy in endometrial polyps: study of 421 women with postmenopausal bleeding.

OBJECTIVE: There is lack of consensus as whether benign-looking endometrial polyps should be removed in postmenopausal women. To help inform clinical practice, this study was conducted to quantify the prevalence and identify the predictors of hyperplasia and cancer in polyps. METHODS: The data of 2625 consecutive women attending a postmenopausal bleeding clinic were collected prospectively in a UK teaching hospital between January 2011 and December 2015. Of them, 421 (16%) women with hysteroscopically benign-looking endometrial polyps with normal background endometrium were included. RESULTS: The number of women with benign polyps versus hyperplasia or cancer in polyps was 387 (92%) vs. 34 (8%). The risk of hyperplasia and cancer in polyps was 5.5-fold and 3.5-fold higher in women with endometrial thickness ≥ 10.8 mm and in women with body mass index ≥ 32.5 kg/m2, respectively. Age, years since last period, ethnicity, recurrent postmenopausal bleeding, diabetes, hypertension, and the use of tamoxifen did not differ between the outcome groups. CONCLUSION: The prevalence of hyperplasia and cancer in benign-looking polyps is high. The independent predictors are body mass index and endometrial thickness. Removal of polyps may be warranted until hysteroscopic morphological criteria that can reliably predict the outcome are established in future research.

Outpatient 'Acute Gynaecology Clinic' - a novel admission avoidance model to improve women care.

This article presents to the gynaecologists, general practitioners, accident and emergency doctors and the policy makers the concept, proposed set-up and the benefits of the outpatient consultant-delivered 'Acute Gynaecology Clinic' as a novel admission avoidance model to improve women care and satisfaction. The service caters for women who present with urgent benign non-pregnancy-related gynaecological conditions not severe enough to necessitate admission or immediate assessment.

Non-hormonal topical treatment of vulvovaginal atrophy: an up-to-date overview.

Vulvovaginal atrophy-related symptoms exert a negative impact on the quality of life of up to 50% of postmenopausal women. Many of them decline to use topical vaginal estrogen, which is the standard effective therapy, due to the adverse publicity over recent years, and seek for alternatives. Further, there are no safety studies to support the use of topical vaginal estrogen in breast cancer survivors, and it is considered as contraindicated by many health-care professionals. Vaginal moisturizers and lubricants as well as regular sexual activity may be helpful to such women. Vaginal moisturizers may have an equivalent efficacy to topical vaginal estrogen and should be offered to women wishing to avoid the use of hormonal therapy. Lubricants are usually used during sexual intercourse to provide temporary relief from vaginal dryness and dyspareunia; however, they have no long-term therapeutic effects. We provide in this systematic review up-to-date information, for women and health-care professionals, about the use, safety and efficacy of the available vaginal moisturizers and lubricants.

Topical vaginal estrogen therapy in managing postmenopausal urinary symptoms: a reality or a gimmick?

Postmenopausal estrogen deprivation has been suggested as a risk factor for lower urinary tract dysfunction including stress incontinence, overactive bladder and recurrent urinary tract infection. These symptoms could have enormous effects on individuals and health-care providers in terms of impact on quality of life and cost. Recent randomized, controlled trials suggested that systemic hormone replacement therapy does have a negative effect on female lower urinary tract function, probably because of the progestogen component. Further, it may be unacceptable for many women because of concerns about breast cancer or the return of withdrawal bleeding. Topical vaginal estrogen preparations reverse urogenital atrophic changes and may relieve associated urinary symptoms while avoiding systemic and progestogenic effects. This article provides an up-to-date overview of the role, effectiveness and safety of topical vaginal estrogen therapy for the treatment of lower urinary tract symptoms in postmenopausal women.

Managing women with post-coital bleeding: a prospective observational non-comparative study.

The management of post-coital bleeding (PCB) is inconsistent in the UK and there are no guidelines to ensure good practice. This prospective study was conducted to review the management and identify the diagnostic outcome of 137 women treated according to a locally devised protocol based on the best available evidence. Women underwent smear testing, taking triple swabs and colposcopy. The endometrium was investigated in postmenopausal women and in those aged >35 years with associated intermenstrual bleeding. Of those who had PCB for >4 weeks, only 8/124 (6.5%) were referred urgently. Twenty eight (20.4%) women were found to have significant pathology; 14 (50%) were <35 years of age, 26 (92.8%) had PCB for >4 weeks, whereas seven (25 %) suffered severe episodes, suggesting that the duration, but not age or severity, is relevant. A large multi-centre study is needed to provide more information in order to optimise the management.

Topical estrogen therapy in the management of postmenopausal vaginal atrophy: an up-to-date overview.

Vaginal atrophy, a manifestation of estrogen deprivation after the menopause, could affect up to 60% of women, with a significant impact on their quality of life. It is often under-diagnosed and inadequately treated. Symptoms are more common and severe in breast cancer survivors. Systemic estrogen replacement therapy may be unacceptable for many women because of the concerns over possible risks and may not cure vaginal symptoms in up to 45% of users. Non-medicated vaginal lubricants or moisturizers have been found to be no better than placebo and less effective than estrogen. Topical vaginal estrogen preparations reverse atrophic changes and relieve associated symptoms, while avoiding systemic effects. This article provides an up-to-date overview of the role, safety and effectiveness of topical vaginal estrogen therapy.

Transdermal natural progesterone cream for postmenopausal women: inconsistent data and complex pharmacokinetics.

Transdermal progesterone cream (PC) is propagated as a possible alternative to hormone replacement therapy (HRT) in the management of menopausal symptoms and treatment of osteoporosis. Nonetheless, considerable concerns were raised regarding the inconsistent results and the credibility of some studies that were not peer-reviewed. Further, the complex nature and diversity of the pharmacokinetics of progesterone led to difficult interpretation of the findings. Given the current best available evidence, using PC for postmenopausal therapy regimens should be considered as an unsubstantiated treatment option, and its clinical applications must be restricted to well-designed interventional trials that assess its efficacy and safety.

Acupuncture in managing menopausal symptoms: hope or mirage?

There is an increased interest amongst women in seeking alternatives for hormone replacement therapy because of their fear of side-effects. It is claimed that acupuncture is effective for curing menopausal symptoms, and to be a safe treatment in the hands of well-trained and qualified practitioners. About one million acupuncture treatments are given in the National Health Service and two million privately each year in England for various indications. However, because its mechanism of action is not fully understood in physiological terms, acupuncture is considered by many clinicians to be of no value. This article reviews the currently available evidence as regards the effectiveness and safety of acupuncture in treating menopausal symptoms.

The outcome of referral with postcoital bleeding (PCB).

We reviewed 284 women with postcoital bleeding (PCB) seen in colposcopy and gynaecology clinics over eight years. 166 women were referred with PCB alone (group 1) and 118 with PCB and abnormal cervical cytology (group 2). The aim was to assess the validity of the Department of Health (DoH) referral guidelines for suspected cancer in women with PCB, to measure the frequency of abnormal findings in these women, and to review the management of PCB with the aim of identifying and addressing deficiencies. No pathology was identified in half of women in group one and in 17% of group two. The rate of cervical cancer was 3.6% in group one and 5% in group two. The equivalent figures for CIN were 9% and 66.1% respectively. There was no significant difference in the prevalence of cervical cancer or CIN between women >?35 years and the rest of women in group one. The management of PCB was inconsistent. Neither age nor duration of PCB was a reliable indicator for cervical cancer. A normal smear record must not be regarded as reassuring in a woman with PCB.

A comprehensive approach to the menopause: so far, one size should fit all.

UNLABELLED: Although extensive studies have indicated that the benefits of hormone replacement therapy outweigh the risks, many women and health care providers have concerns about safety and side effects. Many alternative therapies are popular with patients, and menopausal women in the United States spent more than $600 million in 1999 alone purchasing these therapies. Several of the more commonly used alternative therapies for the menopause are critically appraised in this article. For women who choose not to take estrogen, and for those who do, the additional benefits of calcium, vitamin D, exercise, stress reduction, and different dietary and lifestyle adaptations may enhance the quality of life as they age. Although they have the potential for being effective and safe options, there has been limited clinical research for the other alternative therapies. Gynecologists and other health care providers should be aware of the lack of evidence for the effectiveness of most of these therapies when they address patient's questions and concerns. Our information about alternative therapies will increase in the coming years. Ultimately, the growing number of available treatment choices will allow individualization of the treatment. Nevertheless, until prospective studies with prolonged follow-up are conducted to evaluate the risks and benefits of different alternative therapies, hormone replacement therapy, which is better studied, will remain the treatment of first choice, and "one size fits all" will continue to describe the management plan for most peri- and postmenopausal women at least in the near future. LEARNING OBJECTIVES: After completion of this article, the reader will be able to summarize the various alternatives to hormonal therapy for menopausal symptoms, describe the effects of phytoestrogens in the management of menopausal symptoms, and explain the origin and clinical use of the more common herbal therapies.

A review of gynaecological cancer management: a large West Midlands general hospital experience.

The records of 372 women with gynaecological cancer were reviewed to assess the quality of care which has been given and to compare the standards achieved with those suggested by The West Midlands Gynaecological Oncology Group. The median primary referral interval was 18 days; 54% of patients were seen within 2 weeks of referral. The median interval between first hospital visit and surgery was 32 days and 77.5% of patients had their operation within 8 weeks. The median interval between histology report and starting adjuvant therapy was 19 days and 81% of patients commenced treatment within 6 weeks. The histological diagnosis was available within 2 weeks of surgery in 77% of patients. Less than one-third of patients in our series were referred to the lead consultant of gynaecological oncology, who performed 50% of the operations for gynaecological malignancy. There was no record of the primary referral interval, date of surgery and date of commencement of adjuvant therapy in 35%, 25% and 20% of patients, respectively. More attention must be given to redistribution of caseload with more involvement of the gynaecological cancer team and to improvement in clinical cancer data collection to decrease the extent of missing data. The delays in referral of patients with suspected gynaecological malignancy could be minimised by improving communication between the general practitioners and the hospitals.

Subtotal abdominal hysterectomy: a surgical advance or a backward step?

UNLABELLED: OBJECTIVE To review the short and medium term outcomes of subtotal abdominal hysterectomy. We also describe the management of cervical stump complications by vaginal trachelectomy or large loop excision of the transformation zone. DESIGN: Retrospective analysis. SETTING: Warwick General Hospital, Warwickshire, UK. SAMPLE: One hundred and fifty women underwent subtotal abdominal hysterectomy between 1993 and 1999. Five women had vaginal trachelectomy and another five had large loop excision of the transformation zone for complications relating to the cervical stump. RESULTS: The prevalence of intra-operative and early post-operative complications was 4% and 7.3%, respectively. Twenty women (13.3%) had late complications, of whom 17 (11%) presented with symptoms directly related to the stump (two had also genuine stress incontinence). Three presented with genuine stress incontinence alone. The commonest problem was regular menstruation, which occurred in 12 women (8%). Ten of these women underwent vaginal trachelectomy or large loop excision of the transformation zone. None had intra-operative or post-operative complications. CONCLUSIONS: The high prevalences of cervical stump problems should be taken into account before a change in surgical procedure from total to subtotal hysterectomy is recommended. Further prospective studies with prolonged follow up are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Total hysterectomy, preferably by the vaginal route, remains the procedure of choice for most women. Should a problem develop, vaginal trachelectomy or large loop excision of the transformation zone by an experienced surgeon are the best options for these women.

A review of the treatment failures following cervical intraepithelial neoplasia grade III treated by large loop excision of the transformation zone.

The records of 208 women were reviewed to quantify the long-term treatment failures of large loop excision of the transformation zone (LLETZ) in the treatment of cervical intraepithelial neoplasia (CIN) grade III. The rate of dyskariotic smears fell from 8% at 6 months to 2.3% at 48 months. The excision was considered incomplete in 84 cases (40.3%) of which 40 had endocervical margins involved. Thirty-five per cent of women with incomplete excision of CIN at the endocervical margin and 9% with complete excision had a dyskariotic smear within 4 years following LLETZ. These findings were statistically significant (P = 0.003 and 0.02 respectively). However, 5% only of women in the former group had cytological treatment failure at 6 months. There was no significant association between age and incidence of treatment failure. Further data are required to determine the risk of recurrence beyond 4 years before recommendations could be made about the duration of annual screening.