The influence of unilateral oophorectomy on the age of menopause.

OBJECTIVE: To determine the age of menopause after premenopausal unilateral oophorectomy (UO) and to establish whether UO at a young age leads to menopause at a younger age than if UO occurs at an older age. METHODS: A cohort of 28 731 women, of whom 17 781 (62%) were menopausal, was investigated. Information on menopause was obtained from self-reported questionnaires. Surgical data were obtained from the National Patient Register to avoid recollection bias. Age of menopause after UO/not UO was determined using Kaplan-Meier curves. Cox regression was used to identify factors of importance for early menopause. RESULTS: UO was performed in 1148 women. Women with UO after the age of 45 years, premenopausal hysterectomy, bilateral oophorectomy and cancer were excluded, leaving 236 in the analysis. Menopause occurred 1.8 years earlier after UO compared to women with two intact ovaries (mean 49.5 vs. 51.3 years), and younger age at UO was significantly linearly correlated to younger age at menopause. UO (hazard ratio 1.23) and smoking (hazard ratio 1.12) significantly decreased the age of menopause. CONCLUSIONS: Premenopausal unilateral oophorectomy significantly reduces the age of menopause by 1.8 years. Younger age at UO leads to significantly younger age at menopause.

Adverse effects of perioperative paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review.

Post-operative pain affects millions of patients worldwide and the post-operative period has high rates of morbidity and mortality. Some of this morbidity may be related to analgesics. The aim of this review was to provide an update of current knowledge of adverse events (AE) associated with the most common perioperative non-opioid analgesics: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCCs), gabapentinoids and their combinations. The review is based on data from systematic reviews with meta-analyses of analgesic efficacy and/or adverse effects of perioperative non-opioid analgesics, and randomised trials and cohort/retrospective studies. Generally, data on AE are sparse and related to the immediate post-operative period. For paracetamol, the incidence of AEs appears trivial. Data are inconclusive regarding an association of NSAIDs with mortality, cardiovascular events, surgical bleeding and renal impairment. Anastomotic leakage may be associated with NSAID usage. No firm evidence exists for an association of NSAIDs with impaired bone healing. Single-dose GCCs were not significantly related to increased infection rates or delayed wound healing. Gabapentinoid treatment was associated with increased sedation, dizziness and visual disturbances, but the clinical relevance needs clarification. Importantly, data on AEs of combinations of the above analgesics are sparse and inconclusive. Despite the potential adverse events associated with the most commonly applied non-opioid analgesics, including their combinations, reporting of such events is sparse and confined to the immediate perioperative period. Knowledge of benefit and harm related to multimodal pain treatment is deficient and needs clarification in large trials with prolonged observation.

Post-operative analgesic effects of paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review.

In contemporary post-operative pain management, patients are most often treated with combinations of non-opioid analgesics, to enhance pain relief and to reduce opioid requirements and opioid-related adverse effects. A diversity of combinations is currently employed in clinical practice, and no well-documented 'gold standards' exist. The aim of the present topical, narrative review is to provide an update of the evidence for post-operative analgesic efficacy with the most commonly used, systemic non-opioid drugs, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs)/COX-2 antagonists, glucocorticoids, gabapentinoids, and combinations of these. The review is based on data from previous systematic reviews with meta-analyses, investigating effects of non-opioid analgesics on pain, opioid-requirements, and opioid-related adverse effects. Paracetamol, NSAIDs, COX-2 antagonists, and gabapentin reduced 24 h post-operative morphine requirements with 6.3 (95% confidence interval: 3.7 to 9.0) mg, 10.2 (8.7, 11.7) mg, 10.9 (9.1, 12.8) mg, and ≥ 13 mg, respectively, when administered as monotherapy. The opioid-sparing effect of glucocorticoids was less convincing, 2.33 (0.26, 4.39) mg morphine/24 h. Trials of pregabalin > 300 mg/day indicated a morphine-sparing effect of 13.4 (4, 22.8) mg morphine/24 h. Notably, though, the available evidence for additive or synergistic effects of most combination regimens was sparse or lacking. Paracetamol, NSAIDs, selective COX-2 antagonists, and gabapentin all seem to have well-documented, clinically relevant analgesic properties. The analgesic effects of glucocorticoids and pregabalin await further clarification. Combination regimens are sparsely documented and should be further investigated in future studies.

[Laparoscopically treated extrauterine pregnancy]. / Laparoskopisk behandlet ekstrauterin graviditet.

During a period of 12 months 55 women were treated for 56 ectopic pregnancies. Forty of the 56 (71%) procedures were performed laparoscopically. The duration of operation was 74 minutes when a conservative procedure was used, and 83 minutes where a salpingectomy was performed. The median duration of a diagnostic laparoscopy followed by laparotomy in 12 women was 83 minutes. Four women (13%) had persistent trophoblast, which necessitated a second operation. Two patients had a second laparoscopy because of lower abdominal pain, but did not need further treatment. Median hospitalization time (including diagnosis and second procedures) for the laparoscopically treated women was three days (range one to 16 days).

Herniation of the omentum after laparoscopy.

The use of laparoscopic surgery is increasing. With this new type of surgery new complications will occur. One of these complications is herniation via the troicart incision as a result of the use of large troicarts. This problem could be solved by using the Z-incision technique or by suturing the fascia. Two cases of herniation of the omentum are described and discussed.

Laparoscopic sterilization under local anesthesia.

Fifty-two women were sterilized through laparoscope under local anesthesia with Filshieclips. The majority (94%) were satisfied with the method. During the operation three patients were submitted to general anesthesia due to adhesions (two) and inadequate relaxation (one). Admission period and sick leave were reduced to a minimum.

PIP: Between January, 1991, and May, 1992, gynecologists at Glostrup County Hospital in Denmark performed laparoscopic sterilization (Filshie clips) under local anesthesia on 52 women 25-42 years old. 11 of the women had previously undergone an abdominal operation, especially appendectomy or cesarean section. At the same time of laparoscopic sterilization, 9 women and 2 underwent curettage and legal abortion, respectively. The physicians had to resort to general anesthesia in 3 cases due to discomfort in 1 patient and pelvic adhesions in the other 2 cases. As of 12 months after laparoscopic sterilization, none of the women had conceived. 44 (94%) of the 46 women who responded to the questionnaire were very satisfied with the operation. 96% of those satisfied with the operation would recommend it to others. 40 women were discharged from the hospital on the same day as the laparoscopic sterilization. The others were discharged the day after the operation. Sick leave after discharge ranged from 0-8 days, with the mean being 2-3 days. The 2 women who had undergone simultaneous legal abortion had the most severe discomfort. The physicians recommend that simultaneous legal abortion should not be conducted under local anesthesia. Local anesthesia for sterilization would likely benefit patients with cardial or pulmonary symptoms and those who fear general anesthesia. Based on the high acceptance rate of laparoscopic sterilization under local anesthesia and the need to cut back on costs when possible, the physicians recommend that this method be used more often.

[Is routine microscopy of tissue from induced abortions necessary?]. / Er rutinemaessig mikroskopi af vaev fra provokerede aborter nødvendig?

This study was performed in order to evaluate the importance of routine microscopy of tissue from legal abortions performed before the end of the 12th week of pregnancy. The tissues recovered from 580 abortions were examined carefully macroscopically before they were sent to microscopy. Five hundred and fifty-four samples (95.5%) were judged by macroscopic examination to contain the normal products of pregnancy. These all contained chorionic villi when examined histologically. Macroscopic examination was inconclusive in the remaining 26 samples (4.5%), 22 of these samples proved after all to contain chorionic villi when examined histologically. We conclude that histological examination of tissue from legal abortions is unnecessary in most cases if it is replaced by careful clinical examination of the sample, only to be followed by microscopy if the findings are uncertain.

[Laparoscopic vaginal hysterectomy]. / Laparoskopisk assisteret vaginal hysterektomi.

Laparoscopic assisted vaginal hysterectomy (LAVH) is a rather new operative procedure in Denmark. During the period 1.12.1992-28.02.1993 we performed ten LAVH. The procedure is described. The operations were performed with bipolar coagulation and subsequent cutting with scissors. The average operating time was two hours. The average uterine weight was 130 g and total average hospital stay was two 2.8 days. In one patient laparotomy had to be performed due to arterial bleeding close to the right ureter. One patient developed a postoperative haematoma with temporary stasis of the right ureter. Both patients recovered. Adequate laparoscopic training in humans and animals is mandatory before LAVH is performed. In the learning phase it is advisable that the uterine size does not exceed 200 g.

[Intraobserver and interobserver variation in measurement of the pelvic diameter using DeLee's internal pelvimeter in Cesarean section]. / Intra- og interobservatørvariation ved måling af conjugata vera obstetrica med DeLee's interne pelviometer ved sectio caesarea.

The method of measuring the true conjugata with DeLee's Internal Pelviometer at caesarean section was evaluated. In 58 women the true conjugata were blindly measured three times by the surgeon and also, in fifty cases, three times by the assistant. Only a slight intraobserver difference was found: median range was 0.42 cm. There was no significant interobserver variation. We conclude that DeLee's Internal Pelviometer can be used to measure the true conjugata at caesarean section, but the use of pelviometry in modern obstetrics is questioned.

[New therapeutic methods in tubal pregnancy]. / Nyere behandlingsmetoder ved tubar graviditet.

A world-wide increase in the incidence of extrauterine pregnancy has increased interest in new forms of treatment of this condition. In Denmark, the number of cases of diagnosed tubal pregnancies has doubled from 1980 til 1989. Experience with the spontaneous course of tubal pregnancies is reviewed. In addition, various forms of laparoscopic treatment and systemic and local treatment with methotrexate are described. In Denmark, local treatment with prostaglandin has been employed with good effect. Whether conservative surgical treatment or treatment with methotrexate or prostaglandin are to be employed depends upon the patience of the treating physician as regards control examinations with ultrasonic scanning and measurement of serum human chorion gonadotropin. Repeated tubal pregnancy in the salpinx involved, persisting trophoblastic tissue after treatment and long periods of observation are unintentional side effects of treatment. After conservative treatment of tubal pregnancy, it is important that the patient is given meticulous information.

[Uterine rupture in Denmark during the period 1980-1987]. / Ruptura uteri i Danmark i perioden 1980-1987.

A retrospective review was undertaken of 128 consecutive cases of rupture of the uterus during the eight-year period from 1 Jan 1980-31 Dec 1987. It was found that rupture of the uterus occurs most commonly after previous Cesarean section but that it may occur after other types of operation on the uterus. Rupture of the uterus does not occur in primiparae unless special conditions are present. Potent stimulation appears to involve a slightly increased risk for rupture of the uterus. A great proportion of the ruptured uteri occurred in women who had previously been submitted to Cesarean section on account of breech presentation as primiparae. In subsequent pregnancies, this resulted in three dead infants and four children with severe brain damage.

Hormonal and menstrual changes after laparoscopic sterilization by Falope-rings or Filshie-clips.

OBJECTIVE: To evaluate the influence of laparoscopic sterilization by Falope-rings (Cabot Medical Corp., Langhorne, PA) or Filshie-clips (Femcare, Nottingham, United Kingdom) on menstrual pattern and ovulatory function. DESIGN: A prospective, nonrandomized study of women sterilized by Falope-rings (n = 6) or Filshie-clips (n = 5). Menstrual charts were kept. Serum follicle-stimulating hormone (FSH), estradiol (E2) and progesterone (P) were measured by means of radioimmunoassay in one cycle before and 3, 6, and 12 months after the sterilization. Blood samples were drawn on day -6, -2, 0, +6, +10 of the menstrual cycle, ovulation corresponding to day 0. The women sterilized by Filshie-clips had abdominal ultrasonography of the ovaries measuring the leading follicle on day -6, -2, 0, +6 of the menstrual cycle. PATIENTS: Twelve women, 25 to 38 years old, with regular menstrual cycles and no use of oral contraceptives or intrauterine contraceptive device at least 6 months before sterilization. One woman was excluded. RESULTS: After the sterilization, all women reported unchanged menstrual pattern. The follicular rise in E2 unchanged, and FSH levels fell accordingly. Progesterone levels were ovulatory, but the midluteal P peak 3 months poststerilization was significantly decreased. Serial abdominal ultrasonography in women sterilized by Filshie-clips confirmed ovulation in all cycles except in one woman, who had an unruptured follicle in one cycle before and in the sixth cycle after sterilization. CONCLUSION: Laparoscopic sterilization by Falope-rings or Filshie-clips does not seem to interfere with menstrual pattern or ovulatory function.

PIP: Physicians evaluated the effect of laparoscopic female sterilization by Falope-ring and the Filshie-clip technique on the menstrual pattern, the ovarian endocrine function, and the ovulatory function on 6 women at the Rigshospitalet in Copenhagen, Denmark and on 5 women at Gentofte County Hospital in Denmark. They followed these women from 1-2 months before sterilization and at 3,6, and 12 months after sterilization. The physicians took blood samples on day -6, -2, 0 (menstrual cycle), 6, 10 of the menstrual cycle to measure follicle stimulating hormone (FSH), estradiol, and progesterone. Ultrasonography measured the leading follicle of women sterilized by Filshie-clips on day -6, -2, 0, 6, 10 of the menstrual cycle. None of the 11 25-38 year old women used oral contraceptives or an IUD before the surgery. All experienced regular menstrual cycles. The sterilization did not cause any changes in menstruation. Moreover peak estradiol levels rose during the follicular phase and peak FSH levels decreased as normal. Overall peak progesterone levels stayed within normal limits of the ovulatory cycle, but it fell considerably 3 months after sterilization (p.05) and somewhat significantly 12 months after sterilization. Ultrasonography revealed that only 1 women sterilized by Filshie-clips experienced an unruptured follicle in the cycle before and the 6th cycle after sterilization. All other women sterilized by Filshie-clips experienced normal valuation. Based on these results, the researchers concluded that laparoscopic female sterilization by Falope-rings and the Filshie-clips do not affect the menstrual pattern or ovulatory function.

[Laparoscopic sterilization of women under local anesthesia]. / Laparoskopisk sterilisation af kvinder i lokal anaestesi.

Ten women were sterilized via a laparoscope under local anaesthesia (paracervical blockade and periumbilical infiltration anaesthesia). Sterilization was carried out with simultaneous video monitoring. One patient, in whom termination of pregnancy was performed simultaneously at the end of the first trimester, experienced discomfort. The remaining nine sterilized women were extremely satisfied with the procedure. Laparoscopic sterilization of women in local anaesthesia is a rapid, safe and pleasant procedure for the patients.

PIP: 10 women were sterilized via a laparoscope under local anesthesia (paracervical block and periumbilical infiltration anesthesia). Sterilization was carried out with simultaneous video monitoring. 1 patient, in whom termination of pregnancy was performed at the same time at the end of the 1st trimester, experienced discomfort. The remaining 9 were extremely satisfied with the procedure. Laparoscopic sterilization of women with local anesthesia is a rapid, safe, and pleasant procedure for the patients. (author's modified)

[Ultrasonically guided transvaginal drainage of genital abscesses]. / Ultralydvejledt transvaginal draenage af genitale abscesser.

Abscesses in the true pelvis were previously treated by hysterectomy and bilateral salpingoophorectomy, colpotomy, transabdominal drainage and by antibiotics. In the present material, 16 abscesses in the true pelvis were treated with either establishing of transvaginal drainage or transvaginal puncture with a cannula, both methods ultrasonically guided with a vaginal transducer. Treatment proved effective in 93% of the cases and patients were only hospitalized for an average of 6.7 days after drainage.

[The national patient register--a research tool?]. / Landspatientregisteret--et forskningsredskab?

In connection with an analysis of rupture of the uterus in Denmark during the period 1980-1987, the authors found that 956 patients were registered as having rupture of the uterus in the Danish national patient register. Review of the individual cases revealed that the correct number was only 129, i.e. that only 14.1% were correctly registered. The authors consider it unsatisfactory that such an extensive register of this type cannot be employed without controlling the records of each individual patient.

Sexual adjustment to tubal sterilization.

Sexual adjustment after laparoscopic sterilization has been investigated in a Danish population. The study comprises 659 patients who underwent laparoscopic sterilization during the 4-year period 1980-1983. The study focused on libido, coital frequency, coital enjoyment, lack of excitement, sexual life and feelings of femininity after sterilization in one group of patients satisfied with the sterilization and in another group dissatisfied with the decision to undergo tubal sterilization. There was no difference in libido, coital frequency and sexual satisfaction between the two groups. However, a significant difference was seen between the two groups concerning lack of excitement in sexual life, perception of a more relaxed sexual life, and, finally, perception of changed femininity.

Regret of laparoscopic sterilization.

A follow-up study with questionnaires was performed 4-8 years after laparoscopic sterilization. The follow-up questionnaires were answered for 90.5%. The study revealed that 7.1% of the women were dissatisfied at some stage with the decision to undergo sterilization. However, only 1.8% requested reversal of the sterilization. 40% of the dissatisfied women were between 25-29 years of age, and every fifth sterilized woman in this age group regretted the sterilization.

PIP: To learn more about the extent of and factors associated with regret after laparoscopic sterilization, 659 (90%) of the 755 women who underwent this procedure at Denmark's Herlev Hospital in 1980-83 completed a postal questionnaire in 1987. The questionnaire revealed that, 4-8 years after sterilization, 612 women (93%) were satisfied with the procedure and 47 (7%) had regrets. Parity did not differ significantly between the 2 groups of women (2.4 children among satisfied sterilization acceptors compared to 2.0 among unsatisfied women). Age at sterilization, however, emerged as a significant factor. The mean age of satisfied acceptors was 35.4 years compared to 31.7 years among those who regretted their decision; 40% of women in the latter group were 29 years of age or under. Another significant difference between the 2 groups was in the information provided before surgery. Of the women who regretted undergoing sterilization, 28% felt they had received inadequate counseling and 13% claimed they were not fully informed about the questionable reversibility of the procedure; these percentages among women who were satisfied were 7% and 6%, respectively. The cause of regret in 70% of unsatisfied women was the desire for another pregnancy, generally as a result of remarriage. Of the 47 women who regretted the sterilization, only 12 sought reversal and 7 underwent tubal reanastomosis.

Hysterectomy subsequent to laparoscopic sterilization.

The incidence of hysterectomy for bleeding disorders among sterilized women was compared with the incidence of hysterectomy for bleeding disorders among the female population of the same age in Denmark. The relative risk of undergoing hysterectomy subsequent to tubal sterilization was increased compared to the control group. However, there are several other plausible explanations for this apparently increased risk.

PIP: In 2 groups of women of the same age the incidence of hysterectomy for bleeding disorders was studied. Group I was comprised of 21,642 women aged 25-49 who underwent hysterectomy for bleeding disorders during 1978-1981. Group II included 686 women of the same age range who had hysterectomy subsequent to laparoscopic sterilization. 1/3rd of these women had bleeding disorders, and this group was part of 10,104 patients who were laparoscopically sterilized during 1978-1980. In Group I, 20.5% of the total has hysterectomy for bleeding disorders, whereas this figure rose to 37% in Group II. By calculating the probability of hysterectomy for bleeding disorders among laparoscopically sterilized women taking into account age, the result obtained is 0.44%. However, in Group II the number of hysterectomies was significantly higher. The interval from sterilization to hysterectomy increased with age: 25.2 months in those aged 25-29 and 50.3 months in the 45-49 age group. Younger women of 25-34 years of age had the rate of post-sterilization hysterectomy. The increased risk women who undergo sterilization to face hysterectomy is attributable to multiple factors, such as prior bleeding condition, discontinuation of contraceptive pills, and age.