Recognizing and treating premenstrual dysphoric disorder in the obstetric, gynecologic, and primary care practices.

The author's aim is to aid primary care physicians and obstetrician-gynecologists in correctly diagnosing and treating premenstrual dysphoric disorder (PMDD). The symptoms fluctuate markedly, but their timing is key. PMDD patients experience symptoms only during the luteal phase and will have a symptom-free interval after the menstrual flow and before ovulation. The author discusses self-report instruments, which are valuable tools for diagnosis when combined with the ICD-10 criteria for premenstrual syndrome (PMS) or the DSM-IV criteria for PMDD and the ruling out of medical and psychiatric conditions, such as diabetes, hypothyroidism, major depression, and dysthymia, that cause similar symptoms. Treatment strategies ranging from nonpharmacologic approaches such as dietary modification and aerobic exercise to pharmacologic interventions such as antidepressants, anxiolytics, and agents to suppress ovulation are examined.

Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies.

BACKGROUND: The use of methotrexate for the treatment of women with tubal ectopic pregnancies is now common practice. However, the clinical and hormonal determinants of the success of this treatment are not known. METHODS: We studied 350 women with tubal ectopic pregnancies who were treated with methotrexate intramuscularly according to a single-dose protocol. Pretreatment serum concentrations of human chorionic gonadotropin and progesterone, the size and volume of the gestational mass, fetal cardiac activity, and the presence of fluid (presumably blood) in the peritoneal cavity were correlated with the efficacy of therapy, as defined by resolution of the ectopic pregnancy without the need for surgical intervention. RESULTS: There was no relation between the women's age or parity, the size or volume of the conceptus, or the presence of fluid in the peritoneal cavity and the efficacy of treatment. Among the 320 women in whom treatment was successful (91 percent), the mean (+/-SD) serum chorionic gonadotropin and progesterone concentrations were 4019+/-6362 mIU per milliliter and 6.9+/-6.7 ng per milliliter (21.9+/-21.3 nmol per liter), respectively, as compared with 13,420+/-16,590 mIU per milliliter and 10.2+/-5.5 ng per milliliter (32.4+/-17.5 nmol per liter) (P<0.001 and P=0.02) in the 30 women in whom treatment was not successful. Fetal cardiac activity was present in 12 percent of the successfully treated cases and 30 percent of those in which treatment was not successful (P=0.01). Regression analysis revealed the pretreatment serum chorionic gonadotropin concentration to be the only factor that contributed to the failure rate. CONCLUSIONS: Among women with tubal ectopic pregnancies, a high serum chorionic gonadotropin concentration is the most important factor associated with failure of treatment with a single-dose methotrexate protocol.

Primary care in obstetrics and gynecology resident education: a baseline survey of residents' perceptions and experiences.

OBJECTIVE: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology. METHODS: The Council on Resident Education in Obstetrics and Gynecology In-Service Examination in 1995, given to 4361 residents, who represented all programs in the country, included a questionnaire on whether obstetrics and gynecology was primary care and whether they planned to do primary care after residency. Primary care services were categorized by counseling and screening, as defined by the U.S. Preventive Health Services Task Force. Variables included gender, residency level (upper or lower), and type of residency (community or university based). Data were analyzed using the chi2 text and multiple analyses of variance. RESULTS: The response rate was 94% (4099 of 4361), representing a nationwide complement. Eighty-seven percent of the respondents believed that obstetrics and gynecology was primary care and 85% planned to practice accordingly after residency. Residents spend less than 25% of their time counseling on nongynecologic subjects and less than 25% of their time screening for nongynecologic entities, so their perception as primary care providers focused on traditional obstetric and gynecologic counseling and screening services. When assessments were made by gender, level of training, and type of residency, significant differences were found in many variables regarding counseling and screening practices. CONCLUSION: Our survey results suggest that most American obstetrics and gynecology residents consider obstetrics and gynecology primary care but that there were limitations in the educational venues for learning about nongynecologic primary care before the implementation of the Residency Review Committee Special Requirements. Improvement in nongynecologic primary care teaching is a reasonable expectation because residency programs have had 3 years to institute the mandated changes and provide it to residents.

Practice management in obstetrics and gynecology residency curriculum.

OBJECTIVE: To establish the current level of instruction in practice management in obstetrics and gynecology residency programs; review recommendations of medical school practice management executives and current and former residents on design of practice management instruction programs; and develop recommendations for future management instruction by residency programs in obstetrics and gynecology. METHODS: A questionnaire was sent to 101 practice plan executives of obstetrics and gynecology departments at medical schools in the United States and Canada. A modified version was sent to 44 current obstetrics and gynecology residents and 72 former residents from the University of Tennessee, Memphis. RESULTS: The response rates were 71% (practice executives), 93% (current residents), and 81% (former residents). There were no formal management programs at 87% of responding institutions, although most respondents (62%) thought there should be mandatory participation in management programs, probably given by organizations outside the university. Potential subjects that received high ratings were current procedural terminology and diagnosis coding, managed care, billing procedures, contractual agreements between medical doctors, patient record management, and practice economics. CONCLUSION: Residency programs should establish formal practice management instruction programs and make participation mandatory. Funding should come from the medical school and university. Instructional help should come from extradepartmental organizations and individuals.

Endometriosis and pain.

Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.

Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy.

OBJECTIVE: To evaluate the conservative management of pain after systemic methotrexate therapy for ectopic pregnancy; identify prognostic factors for success; and compare hCG resolution time for patients with and without pain. METHODS: A retrospective review of patients with ectopic pregnancy requiring evaluation for pain after receiving single-dose methotrexate therapy is performed. Results of hematocrits, ultrasound findings, hCG levels, time for hCG levels to reach less than 15 mIU/mL, and outcome were noted. RESULTS: Fifty-three patients with 64 episodes of pain were identified. Seven hospitalized patients required surgery during admission. Two previously hospitalized and one outpatient also ultimately underwent surgery. For hospitalized patients, there were no statistical differences between patients who did or did not undergo surgery during admission for any variable studied, including the presence of free peritoneal blood or rebound tenderness. However, comparison of hospitalized and nonhospitalized patients showed those with rebound tenderness were more likely to be admitted. Hospitalized patients not requiring surgery had shorter resolution time than nonhospitalized patients. For hospitalized and nonhospitalized patients, the median time from treatment to presentation for pain was 8 days. CONCLUSION: The occurrence of pain following methotrexate therapy for ectopic pregnancy should not be the sole indication for surgical intervention. The majority of stable patients with pain after methotrexate therapy, even with rebound or free peritoneal fluid, can be treated successfully without surgery, either in hospital with close observation for severe pain or as outpatients for patients with less severe pain.

Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group.

OBJECTIVE: To evaluate and compare the safety and efficacy of leuprolide versus placebo in managing chronic pelvic pain in women with clinically suspected endometriosis. METHODS: Women 18-45 years of age with moderate to severe pelvic pain of at least 6 months' duration underwent extensive, noninvasive diagnostic testing and laboratory evaluation, including pelvic ultrasound, complete blood count, determination of erythrocyte sedimentation rate, and endocervical cultures. Those with clinically suspected endometriosis were randomized to double-blind treatment for 3 months with depot leuprolide (3.75 mg/mo) or placebo. The accuracy of the clinical diagnosis of endometriosis was evaluated by posttreatment laparoscopy. RESULTS: Of 100 women randomized, 95 completed the study: 49 in the leuprolide group and 46 in the placebo group. Women in the leuprolide group had clinically and statistically significant (P < or = .001) mean improvements from baseline after 12 weeks of therapy in all pain measures. These mean improvements were significantly greater (P < or = .001) than those in the placebo group. At 12 weeks, mean decreases in physician-rated scores for dysmenorrhea, pelvic pain, and pelvic tenderness were 1.7, 1.0, and 0.8 points greater, respectively, in the leuprolide group than in the placebo group (on a four-point scale). Thirty-eight (78%) of 49 and 40 (87%) of 46 patients in the leuprolide and placebo groups, respectively, had laparoscopically confirmed endometriosis after 12 weeks of treatment. No women withdrew from the study because of adverse events. CONCLUSION: Depot leuprolide was effective and safe for treating patients with chronic pelvic pain and clinically suspected endometriosis, confirming the potential of its empiric use in these patients.

Aspiration and microscopy in the diagnosis of ectopic pregnancy.

OBJECTIVE: To compare Karman cannula aspiration followed by dissecting microscopy with suction curettage and permanent histology in obtaining and identifying chorionic villi. METHODS: Karman cannula aspiration was performed before standard curettage for failed intrauterine pregnancies (N=22) or possible ectopic gestation (N=24). Dissection microscopy for chorionic villi was performed on aspirates before submission for permanent histology. Sensitivity, specificity, positive and negative predictive value of each method in obtaining and identifying villi was determined. RESULTS: Overall, all methods were only moderately sensitive in detecting chorionic villi (50-76%). If failed intrauterine pregnancies were excluded, all methods had poor sensitivity (25-64%). However, if villi were detected, the positive predictive value of all methods was high (> 80%). CONCLUSIONS: Karman cannula aspiration followed by dissecting microscope examination or permanent histology may offer an alternative to traditional curettage in the diagnosis of ectopic gestations. A larger trial to validate these findings seems justified.

Applications for residency programs in obstetrics and gynecology, 1996-1997.

OBJECTIVE: The purpose of this work is to report on application patterns for residency positions in obstetrics and gynecology. METHODS: The Electronic Residency Application Service (ERAS) of the Association of American Medical Colleges (AAMC) records each application for a position in a participating residency program. In the 1996-97 application cycle, all but 16 obstetrics and gynecology residency programs participated. Electronic records were analyzed to obtain a statistical picture of the residency application process. RESULTS: Applications for residency positions in obstetrics and gynecology were processed for 1607 graduates of US medical schools, including 110 graduates of osteopathic medical schools. Canadian applicants were six, and other foreign applicants numbered 524. More than two-thirds of US applicants were women, and nine of ten were citizens or permanent residents. Most applicants sent official United States Medical Licensure Examination (USMLE) transcripts to all programs to which they applied. Ninety-five percent of applicants supplied an e-mail address. CONCLUSION: The introduction of ERAS has been successful for obstetrics and gynecology and has provided new information about patterns of applications. The ease of application using the electronic system did not lead to a substantial increase in numbers of applications. Statistics regarding the number of applicants, ratio of women to men, and participation of foreign medical graduates will be of interest to manpower planners.

To what extent do premenstrual and interictal dysphoric disorder overlap? Significance for therapy.

BACKGROUND: Premenstrual dysphoria has shown a significant relationship to epilepsy, and its symptoms correspond to those of the interictal dysphoric disorder. The established treatment for interictal dysphoric disorder is explored as an effective treatment for premenstrual dysphoria. METHODS: Women with premenstrual dysphoria (the majority with epilepsy) were evaluated and treated systematically. RESULTS: Premenstrual disorder responded well to the combination of antidepressant and antiepileptic medication. CONCLUSION: Concordance of symptomatology between interictal and premenstrual dysphoric disorder may extend to treatment. LIMITATIONS: The treatment needs to be evaluated in a large series of women without epilepsy. CLINICAL RELEVANCE: A novel understanding and treatment of premenstrual dysphoria is suggested.

Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate.

OBJECTIVES: The objective of this study was to review the largest single series of ectopic pregnancies treated with single-dose methotrexate reported to date. STUDY DESIGN: A review of 315 patients with unruptured ectopic pregnancies treated with single-dose methotrexate 50 mg/m2 from March 21, 1990, to March 1, 1997, was performed. RESULTS: Overall 287 patients were successfully treated with methotrexate for a success rate of 90.1%. Six patients electively withdrew and requested surgery within 1 week of starting therapy. Excluding withdrawals the overall success rate was 92.9%. Ten patients with an ectopic pregnancy > 3.5 cm but < or = 4 cm in size were treated for a 90% success rate. Forty-four patients with positive ectopic cardiac activity were treated with an 87.5% success rate. CONCLUSIONS: This large series indicates that single-dose intramuscular methotrexate for treatment of ectopic pregnancy is associated with an excellent overall success rate.

What to expect from a residency program: answers from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer questions about obstetric-gynecologic resident salary, night call, vacation, outside employment, gender mix, and training experiences using data from a national directory of residency programs in obstetrics and gynecology. METHODS: The 259 US civilian residency programs were analyzed, using information from the 1996 directory database. We compared programs by size (four or fewer residents per year versus more than four residents per year) and geographic region for each of the questions. We used parametric and nonparametric statistical tests to determine statistical significance. RESULTS: First-year residents earn an average of $31,414 annually and receive a 5% increase each year, although salary varies significantly by region. Residents are on call an average of every 3rd night (twice a week) in the 1st year and every 4th or 5th night in the chief year. Residents in small programs take more night call than those in large programs. A separate night call rotation was more common in large programs. Vacation time varied by year of training and region. Male-to-female ratios in training differed significantly by year in training, program size, and region. The median number of training experiences was identified in each of the categories required by the Residency Review Committee in obstetrics and gynecology. Training experiences varied significantly by program size in three of the 15 categories. CONCLUSION: Program size and geographic region should be considered when comparing programs with regard to pay, work, time off, outside employment, gender mix, and training experiences. Program advisors and potential applicants are encouraged to use this information in comparing programs.

Answers to applicant selection from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer six questions applicants commonly ask of programs, using the data base of a directory of residency programs in obstetrics and gynecology. METHODS: We analyzed data from a directory of 258 civilian residency programs in the United States compiled from a 1994-1995 survey. We expanded the analysis to compare small and large residency programs on the six questions. RESULTS: The average-size program of four residents per year received 50 applications for each position, offered interviews to less than a third of its applicants, and interviewed 15 applicants for each position. An interview gives an applicant a 7% chance of matching with a program. Small programs (fewer than four residents per year) interviewed more of their applicants than did large programs. Programs reported that their residents' scores on part I ranged from the 25th to the 90th percentile, and on part II from the 38th to the 92nd percentile. In general, residents in large programs scored better on these tests than did residents in small programs. Most programs (74%) considered electives beneficial in obtaining a residency position and reported a higher percentage of elective takers than programs without this policy. One in four residents in a program either took a senior elective there, graduated from the same institution, or both. Residents from programs offering fellowship training were twice as likely to pursue fellowship training than residents from programs with no fellowships. Large programs were four times more likely to sponsor fellowships than were small programs. CONCLUSION: Getting an interview in a residency program is a major accomplishment, whereas becoming known in a program may improve the applicant's odds of matching there. Applicants should review a program's policy on electives and selection record. Those considering fellowships should probably apply to programs that offer them. The directory offers a valuable data source for comparing residency programs in obstetrics and gynecology.

A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting.

OBJECTIVE: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance. DESIGN: A retrospective review of charges. SETTING: The Regional Medical Center, Memphis, Tennessee. PATIENTS: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization. MEASUREMENTS AND MAIN RESULTS: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment. CONCLUSION: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Peritoneal closure at vaginal hysterectomy: a reassessment.

OBJECTIVE: To evaluate the clinical outcome of patients who underwent vaginal hysterectomy with or without peritoneal closure. METHODS: This study was a randomized trial. Using computer-generated numbers, all patients undergoing vaginal hysterectomy without oophorectomy were randomized to either no peritoneal closure (n = 57) or routine peritoneal closure (n = 49). Patients were followed-up for a minimum of 1 year for development of complications and postoperative dyspareunia. At 4-6 postoperative weeks, the distance between the ovaries and the vaginal cuff was measured by ultrasound. RESULTS: Postoperative complications were similar in both groups. The incidence of deep-thrust dyspareunia at 6 and 12 months was also similar. No statistical differences between the two groups were noted in the ovary to vaginal cuff distances either overall or when patients with dyspareunia were considered separately. CONCLUSION: The data in this study do not support the use of reperitonealization on a routine basis. However, because of a lack of statistical power, larger studies will be required to confirm this theory.

Chronic pelvic pain.

The basic approach to the patient with chronic pelvic pain as practiced at the University of Tennessee, Memphis, has been described here. Using this approach allows the practicing physician to evaluate and manage realistically or refer appropriately most patients with chronic pelvic pain. The key to management of patients who have chronic pelvic pain is to use any and all available diagnostic and therapeutic modalities to identify the source(s) and direct therapy. By having at least a working knowledge of the various diagnostic and therapeutic modalities available to the patient, the individual clinician can better aid the patient in her understanding of chronic pelvic pain, generally, and her own pelvic pain, specifically.

Development of a program teaching laparoscopic sterilization using local anesthesia.

A program teaching laparoscopic sterilization using local anesthesia was developed and implemented in a large residency program in which sterilization using general anesthesia was already being taught in a traditional fashion. Important steps for the development of such a program included the designation of an individual with overall responsibility for the program, identification of potential obstacles along with feasible solutions, and training of residents and staff in the new techniques. The major obstacles to implementation included opposition from anesthesia personnel, the need for additional training in the new techniques for both residents and faculty, nursing staff resistance, and the uncertainty of patient acceptance. Solutions included involving anesthesia personnel in program planning as well as in the ultimate performance of the procedures, practicing local techniques during cases under general anesthesia, limiting initial cases to candidates anticipated to be uncomplicated, and using nondirective counseling of patients. Similar strategies can be useful both to other residency programs and individuals wishing to offer local anesthesia as an option for laparoscopic sterilization at their hospitals.

The in-training examination in obstetrics and gynecology: an attempt to establish a remediation indicator.

OBJECTIVE: With the use of a university- and community hospital-based faculty, we attempted to determine at what performance level remediation would be recommended. STUDY DESIGN: The Committee on In-Training Examinations for Residents in Obstetrics and Gynecology Task Force on Standard-Based Scoring sent the 1991 examination to 16 university- and 12 community hospital-based faculty members. Given a standardized definition of a "borderline third-year resident," each faculty scored each item on the examination on whether that hypothetic resident would or would not correctly answer the item. RESULTS: The mean expectation of correct responses on the 397-item test was 236 (59%). This was identical to the score obtained if 2 SDs were subtracted from the actual mean for all third-year residents taking the examination. University- and community hospital-based faculty members had generally similar expectations of this defined resident. CONCLUSION: Although poor examination results should not be recommended as the sole determinant for promotion, it appears that 2 SDs below the mean may be an appropriate score below which remediation could be recommended.