Is 2-dimensional transvaginal ultrasonography necessary 6 weeks after insertion of the levonorgestrel 52-mg intrauterine device?

BACKGROUND: In Dutch practice, gynecologists are used to assessing the position of the LNG-IUD by performing a two-dimensional transvaginal ultrasonography (TVUS) directly after insertion and do not routinely invite patients for another consultation 4-12 weeks after insertion. There is no consensus whether a TVUS six weeks after insertion is routinely needed. OBJECTIVE: This study aimed to assess the incidence of malposition using 2-dimensional transvaginal ultrasonography during routine investigation 6 weeks after insertion. In addition, we investigated the relationship between malposition of the levonorgestrel 52-mg intrauterine device and unfavorable bleeding patterns and pelvic pain. STUDY DESIGN: We performed a large prospective cohort study. Patients seeking a levonorgestrel 52-mg intrauterine device were eligible for inclusion. Transvaginal ultrasonography was performed to check position of the levonorgestrel 52-mg intrauterine device immediately after insertion and 6 weeks later. Patients filled in questionnaires about bleeding pattern and pelvic pain 6 weeks after insertion. RESULTS: From March 2015 to December 2016, we enrolled 500 patients. Data from the transvaginal ultrasonography assessment 6 weeks after insertion were available for 448 patients, and complete data (transvaginal ultrasonography and questionnaire data) were available for 363 patients (72.6%). Malposition rate was 6.3% (28/448 patients). Malposition was seen in 15 of 198 patients (7.6%) with unfavorable bleeding and/or pelvic pain and in 3 of 165 patients (1.8%) with favorable bleeding patterns and no pelvic pain (P=.03).Malposition was seen in 14 of 186 patients (7.5%) with an unfavorable bleeding pattern and in 4 of 177 patients (2.3%) with favorable bleeding patterns (P=.008). Malposition was seen in 5 of 50 patients (10%) with pelvic pain and in 13 of 313 patients (4.2%) without pelvic pain (P=.08). CONCLUSION: The malposition rate of the levonorgestrel 52-mg intrauterine device observed using transvaginal ultrasonography 6 weeks after insertion was 6.3%. If patients have no complaints of unfavorable bleeding and/or pelvic pain, the risk for malposition is low (1.8%) and a routine transvaginal ultrasonography is not necessary. However, if patients experience unfavorable bleeding, a transvaginal ultrasonography should be considered to exclude malposition, because the effect of malposition on contraceptive effectiveness is unsure. Future research should focus on cost-benefit analysis.

Microvascular function has no menstrual-cycle-dependent variation in healthy ovulatory women.

OBJECTIVE: Hyper- and hypoestrogenism that persist for a long time can affect vascular and metabolic function. However, it is not clear whether the same is true for subtle sex hormone changes (i.e., during the menstrual cycle). METHODS: Twenty-one healthy normal-weight women with regular cycles were studied during the early-follicular (day 3 +/- 2), late-follicular (day 12 +/- 2), and midluteal (day 20 +/- 3) phases. Microvascular function was assessed by skin iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP), by skin-capillary recruitment after arterial and venous occlusion (i.e., capillaroscopy), and by Fourier analysis of resting skin laser Doppler flow at rest (i.e., vasomotion). Insulin sensitivity (i.e., homeostasis model assessment) and blood pressure were also determined during the study days. RESULTS: Three women were excluded from analyses because they were anovulatory. Skin microvascular responses to ACh and SNP, capillary function, vasomotion, insulin sensitivity, and blood pressure did not differ between the three phases (P > or = 0.1). Further, microvascular function did not correlate with plasma-estrogen levels (r = -0.06-0.2; P> or = 0.2). CONCLUSIONS: Microvascular function does not demonstrate a clear menstrual-cycle-dependent variation.

Obese but not normal-weight women with polycystic ovary syndrome are characterized by metabolic and microvascular insulin resistance.

CONTEXT: Polycystic ovary syndrome (PCOS) and obesity are associated with diabetes and cardiovascular disease, but it is unclear to what extent PCOS contributes independently of obesity. OBJECTIVE: The objective of the study was to investigate whether insulin sensitivity and insulin's effects on the microcirculation are impaired in normal-weight and obese women with PCOS. DESIGN AND POPULATION: Thirty-five women with PCOS (19 normal weight and 16 obese) and 27 age- and body mass index-matched controls (14 normal weight and 13 obese) were included. Metabolic Insulin sensitivity (isoglycemic-hyperinsulinemic clamp) and microvascular insulin sensitivity [endothelium dependent (acetylcholine [ACh])] and endothelium-independent [sodium nitroprusside (SNP)] vasodilation with laser Doppler flowmetry was assessed at baseline and during hyperinsulinemia. MAIN OUTCOME MEASURES: Metabolic insulin sensitivity (M/I value) and the area under the response curves to ACh and SNP curves were measured to assess microcirculatory function at baseline and during insulin infusion (microvascular insulin sensitivity). RESULTS: Obese women were more insulin resistant than normal-weight women (P < 0.001), and obese PCOS women were more resistant than obese controls (P = 0.02). In contrast, normal-weight women with PCOS had similar insulin sensitivity, compared with normal-weight women without PCOS. Baseline responses to ACh showed no difference in the four groups. ACh responses during insulin infusion were significantly greater in normal-weight PCOS and controls than in obese PCOS and controls. PCOS per se had no significant influence on ACh responses during insulin infusion. During hyperinsulinemia, SNP-dependent vasodilatation did not significantly increase, compared with baseline in the four groups. CONCLUSION: PCOS per se was not associated with impaired metabolic insulin sensitivity in normal-weight women but aggravates impairment of metabolic insulin sensitivity in obese women. In obese but not normal-weight women, microvascular and metabolic insulin sensitivity are decreased, independent of PCOS. Therefore, obese PCOS women in particular may be at increased risk of metabolic and cardiovascular diseases.

Superiority of skinfold measurements and waist over waist-to-hip ratio for determination of body fat distribution in a population-based cohort of Caucasian Dutch adults.

OBJECTIVE: To determine which anthropometric measurement is the most reliable alternative for fat distribution as measured by dual-energy X-ray absorptiometry (DXA). DESIGN: Population-based survey carried out in Amsterdam, The Netherlands. SUBJECTS AND METHODS: A total of 376 individuals (200 women) with a mean age of 36.5 years and mean body mass index (BMI) of 24.0 (+/-3.1) kg/m2 underwent various anthropometric and DXA measurements of central (CFM) and peripheral fat mass (PFM). Furthermore, for the assessment of apple-shaped body composition, CFM-to-PFM ratio was calculated. Anthropometric measurements were waist and hip circumference, waist-to-hip ratio (WHR), BMI, waist/length and the skinfold thickness of biceps, triceps, suprailiacal (SI), subscapular (SS) and upper leg. We determined whether equations of combined anthropometrics were even more reliable for the assessment of fat mass. RESULTS: In both women and men, reliable alternatives for CFM are central skinfolds and waist (Pearson's correlation (r) >or= 0.8). Peripheral skinfolds are the best predictors of PFM (r >or= 0.8). In contrast, WHR correlated only marginally with any of the DXA measurements. Equations based on several anthropometric variables correlate with CFM even better (R2 >or= 0.8). CFM-to-PFM ratio has the highest correlation with the ratio (SS+SI)/BMI in women (r = 0.66) and waist/length in men (r = 0.71). Equations are reasonable alternatives of CFM-to-PFM ratio (R2 >or= 0.5). CONCLUSION: Waist and skinfolds are reliable alternatives for the measurement of body fat mass in a cohort of Caucasian adults. WHR is not appropriate for the measurement of fat distribution.