Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years.

OBJECTIVE: To estimate the prevalence of endometrial polyps and to investigate associated abnormal uterine bleeding in a Danish population aged 20-74 years. METHODS: This was a study of a random selection of women from the Danish Civil Registration System: 1660 women were invited of whom 686 were included (429 pre- and 257 postmenopausal). AUB was assessed by a validated questionnaire. The women underwent transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH). Hysteroscopic resection was performed in cases with suspected focal intrauterine pathology. Full evaluation was performed in 619 women (two failures of TVS and 60 failures of SCSH, in two women SCSH was contraindicated (endometrial cancer), in two women hysteroscopy was contraindicated, and one polyp was lost before histology). World Health Organization histopathological criteria were used for diagnosing true endometrial polyps. RESULTS: On final diagnosis there were 48 women with polyps, eight with submucosal myomas, four with other benign findings and one with polypoidal growing endometrial cancer. Complex hyperplasia without atypia was diagnosed in two women with polyps. The prevalence of endometrial polyps was 7.8% (48/619; 95% CI, 5.6-9.9%). The prevalence was influenced significantly by age (P<0.005); in women below the age of 30 years, the prevalence was 0.9%. Polyps were diagnosed in 5.8% of pre- and 11.8% of postmenopausal women (P<0.01). Thirty-nine (82%) of the women who had histopathologically verified polyps were asymptomatic. In asymptomatic premenopausal women the prevalence of polyps was 7.6%, while it was 13% in asymptomatic postmenopausal women. AUB, in particular intermenstrual bleeding, was more frequent among women without polyps (38%). By ultrasound examination, submucosal myomas were diagnosed in 4.2% (26/622; 95% CI, 2.6-5.8%) and intramural myomas in 11.1% (76/684; 95% CI, 8.8-13.5%) of women. Polyps were diagnosed in 2% of oral-contraceptive and 25% of hormone-therapy users. CONCLUSIONS: The overall prevalence of endometrial polyps was 7.8% and the prevalence increased with age. Polyps were rare (0.9%) in women below the age of 30 years. Surprisingly, AUB was less frequent among women with polyps than among those without polyps.

Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a large randomized, double-blind study.

OBJECTIVE: To confirm the advantages of goserelin prior to endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Multicenter, prospective, randomized, double-blind study. PATIENT(S): Cycling premenopausal women with dysfunctional uterine bleeding. TREATMENT: Patients were randomized to goserelin or placebo (sham depot) once monthly for 2 months prior to endometrial ablation. Treatment was timed to allow surgery 6 weeks later on day 7 of the menstrual cycle. MAIN OUTCOME MEASURE(S): Amenorrhea rates, endometrial histology and thickness, pain and blood loss scores, and surgical parameters. RESULT(S): At 24 weeks after surgery, significantly more goserelin than placebo patients experienced amenorrhea (40% versus 26%). Blood loss was reduced from baseline, but not different between the groups. At surgery, mean endometrial thickness was 1.6 mm and 3.4 mm for the goserelin and placebo groups, respectively, with significantly more atrophic glands and stroma in the goserelin group. Surgery was significantly shorter (by 22%) and easier in the goserelin than in the placebo group, with a significantly lower median fluid absorption in the goserelin groups. In both groups, pain scores were reduced patient satisfaction was high (> 92%), and re-intervention rate was low (2.8%). CONCLUSION(S): Goserelin in combination with endometrial ablation was superior to endometrial ablation alone for the treatment of dysfunctional uterine bleeding.

Goserelin Acetate as Adjunctive Therapy for Endometrial Ablation in Women with Dysfunctional Uterine Bleeding

The multinational, multicenter, prospective, double-blind study compared randomized 358 premenopausal women with regular cycles to receive two injections 1 month apart of goserelin acetate depot or sham depot before endometrial ablation. Injections were started to permit surgery (resection ± rollerball) 6 weeks later on day 7 of the cycle when the endometrium would be at its thinnest for the sham group, and allowing down-regulation to continue after surgery. End points were endometrial thickness at surgery, change in blood loss score, amenorrhea, severe hypomenorrhea (score <10), ease and duration of surgery, fluid absorption, change in pain score and endometrial histology. Intent-to-treat analysis was performed. Significantly more women receiving goserelin experienced amenorrhea (40%) than those receiving sham (26%, p = 0.004). The change in blood loss score was significantly reduced from baseline but not different between the groups. The combination of amenorrhea and severe hypomenorrhea favored the goserelin group (p = 0.059). Mean endometrial thickness for goserelin was 1.6 mm and for sham 3.4 mm (p = 0.0001). The majority of women given goserelin had atrophic glands and stroma. Surgery in these patients was significantly shorter (22%, p = 0.0001) and easier than for those treated with sham (p = 0.0001). Operative complications were similar between the groups, with a small but significant difference in favor of goserelin for less fluid absorption (p = 0.04). Pain scores were reduced in both groups. Patient satisfaction was very high in both groups (>92%) with a very low reintervention rate (2.8% for both groups). Overall menstrual loss was reduced. Despite timing the surgery to favor the sham group, the goserelin-treated women had significantly more amenorrhea and significant thinner endometria than seen in the immediate postmenstrual phase, and this resulted in significantly shorter and easier surgery.

Induction of labor by vaginal prostaglandin E2. A randomized study comparing pessaries with vaginal tablets.

A prospective randomized study of 267 pregnant women was undertaken to compare the efficacy of a pharmacy-prepared 3-mg prostaglandin E2 (PGE2) vaginal suppository with a 3-mg PGE2 vaginal tablet for induction of labor and cervical ripening. No statistically significant difference in success frequency was found between the two groups, either on the first day (72% and 74%, respectively; p greater than 0.05) or on the second day (89% in both groups). There was an equal proportion of women requiring oxytocin augmentation in the two groups, but the slower releasing properties of the vaginal tablet were reflected in a longer mean induction--delivery interval of about 4 h for this group. In both the pessary and the vaginal tablet groups, women who had not gone into labor on the first day showed a statistically significant increment in the Bishop score on the morning of the second day. The frequency of cesarean section was the same in both groups, but instrumental deliveries were more frequent in the vaginal tablet group. It is concluded that PGE2 vaginal tablets--a chemically stable alternative to pharmacy prepared pessaries--appear to be effective as regards cervical ripening as well as for labor induction.

Estimated prevalence of müllerian anomalies.

Among 167 women who underwent laparoscopic sterilization in the course of one year, 1.2% were found to have a bicornuate uterus. Of them, 111 were offered follow-up by hysterosalpingography (HSG), and the history of their menstrual pattern as well as reproductive potential was recorded. Evaluation of the HSG exposures revealed 3.6% moderately to severely septate uteri (H/L greater than 0.20), and a total of 15.3% had fundal anomalies (H/L greater than 0.10). In women who had always had normal fertility and menstrual cycles of less than 35 days, the corresponding frequencies of septate uterus were 1.2% and 11.8% respectively. Among women who had had oligomenorrheic periods exceeding one year in duration, the frequency of müllerian anomalies was significantly higher (21.1% at H/L greater than 0.20 and 36.8% at H/L greater than 0.10) than in the above-mentioned groups. A control group of infertile oligomenorrheic women revealed that the material was comparable with previously published populations as regard the occurrence of minor müllerian anomalies. It is concluded that the HSG-diagnosed prevalence of developmental uterine anomalies is in general somewhat higher than usually assumed.

Obstetric behavior and ultrasonic uterine characteristics of oligomenorrheic women.

Two groups of age-, parity-, and pregnancy-matched women, viz. 78 with oligomenorrhea (A) and 78 with normal menstrual intervals (B), plus all women with regular menstruation but in whom severe Müllerian malformations had been diagnosed during the same period (C) were followed in a prospective study to detect complications, sonographic changes, and the serum oxytocinase concentration during pregnancy and labor. Among the matched groups A and B, ultrasonic scanning revealed uterine changes in 45% and 9%, respectively (p less than 0.0005) during the 2nd trimester. Among the oligomenorrheic women who had HSG, fairly mild Müllerian malformations were found in 40%. The sonographic method in these mild and moderate anomalies had its limitations, and the findings were interpreted in several cases as fibroma or contractions. Complications occurred in 51% of the group A women who carried their pregnancies to term versus 20% in group B (p less than 0.0005). Among the primiparae the complication rates were 47% and 22%, respectively (p less than 0.025). Bleeding in early pregnancy (25%), an unstable fetal lie (28%), malpresentations (14%), and premature contractions or delivery (11%) were more common in group A (p less than 0.05-0.01). On stratification of the oligomenorrheic group without or with Müllerian anomalies (A1 and A2) the overall complication rates were 55% and 73%, respectively, and 86% in group C. Mutually, these differences are not statistically different, but all differ significantly from the control group (B) (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy outcome after metroplasty in women with müllerian anomalies.

Pregnancy outcomes in 22 consecutively operated women with Müllerian anomalies are described. In 16 women the indication for metroplasty was two or more spontaneous abortions and/or premature deliveries. The frequency of successful pregnancies increased from 5% before to 76% after operation. In 6 women metroplasty was performed on account of infertility. It is argued that infertility rarely constitutes an indication for metroplasty, and only when concurrent causes of infertility have been excluded. Several of the postoperative pregnancies and deliveries presented serious complications. Cesarean section is therefore recommended in some deliveries after metroplasty.

Ovarian cysts in women with inflammatory bowel disease.

The frequency of ovarian cysts in patients with Crohn's disease (CD) or ulcerative colitis (UC) is believed to be higher than in the normal population, but this aspect has not been studied hitherto. The prevalence of ovarian cysts in the normal population is unknown. By ultrasonic scanning, we studied the frequency of ovarian cysts in 61 patients with CD, 64 with UC, and in 100 controls. The findings were positive in 3 out of 61 with CD, 5 of 64 with UC, and in 2 of 100 controls. There is a tendency to a higher frequency of ovarian cysts in patients with inflammatory bowel diseases than in the normal population, but no statistically significant difference.

Intrathecal administration of morphine for the relief of pains in labour and estimation of maternal and fetal plasma concentration of morphine.

Thirteen healthy women in active labour received an intrathecal injection of morphine 1.0 mg. Eighty-five percent (11 patients) experienced acceptable or good pain relief. Analgesia set in 15-45 min after injection and reached a maximum after 15-120 min and lasted until delivery. Eighty-five percent (11 patients) of the patients developed mild side-effects i.e., pruritus, nausea and emesis. The intrathecal injection of morphine did not adversely affect the condition of the infant. Venous blood samples from the patients and umbilical cords for estimation of plasma morphine showed extremely low concentrations. No patients experienced any discomfort during the injection of morphine. These results indicate that morphine 1.0 mg administered intrathecally decreases labour pains to an acceptable level.

Midtrimester abortion by intracervical prostaglandin E2.

Seventy-six consecutive patients undergoing midtrimester abortion were randomly divided into treatment with either intracervical and (less so) extraamniotic prostaglandin E2 (PGE2) gel or intraamniotic prostaglandin F2 alpha (PGF2 alpha). At the end of 5 h the initial treatment was supplemented by an oxytocin drip and in the PGE2 group the intracervical application of gel was repeated if necessary. The second day a third application of PGE2 gel was administered to a few women. The two groups were comparable with regard to age, parity and gestational age. There was no statistical difference between the two groups in success rate during the 48 h study period (93% for PGE2 versus 97% for PGF2 alpha) or in the average induction-to-abortion interval (16.8 h for PGE2 versus 16.6 h for PGF2 alpha). The frequency of completed abortions was statistically significantly higher and the gastrointestinal side-effects significantly lower in the PGE2-treated patients as compared to the PGF2 alpha-treated subjects. Further, there were fewer complications and the pethidine consumption in women treated with intracervical PGE2 was lower as compared to patients treated with intraamniotic PGF2 alpha. In conclusion, an intracervical PGE2 gel is found applicable and more advantageous than intraamniotic PGF2 alpha in midtrimester abortion. It is safe, convenient and equally easy to administer during the early and the later parts of the second trimester.

Suprapubic versus transurethral bladder drainage after colposuspension/vaginal repair.

Ninety-two patients with preoperative sterile urine undergoing colposuspension or vaginal repair operation for stress urinary incontinence and/or genital descensus were randomized to either suprapubic or transurethral postoperative catheter drainage. The prevalence of significant bacteriuria on the fifth postoperative day was statistically significantly lower when using suprapubic catheter (20.8%) than with transurethral catheter drainage (45.5%). This applied especially to colposuspension. The rate of postoperatively impaired bladder emptying also tended to be reduced when using suprapubic catheter. At follow-up after one year, postoperative bacteriuria was closely correlated to increased rates of both clinical cystitis and asymptomatic significant bacteriuria. Thus it is recommended to use suprapubic bladder drainage not only after colposuspension but also after vaginal repair in an effort to avoid an increased risk of urinary infections.

Randomized trial of intracervical prostaglandin E2 gel and intraamniotic prostaglandin F2 alpha for induction of second trimester abortion.

For the purpose of reducing the side effects and complication rate when inducing second trimester abortion, intracervically administered PGE2 gel was tested for the first time and compared with a single intraamniotic instillation of PGF2 alpha by a randomized allocation of 41 consecutive patients in the 13th to 24th week of gestation. In both groups the treatment was supplemented with oxytocin 5 - 6 hours after starting the induction. The methods proved of equal value as regards the abortion success rate and the induction-abortion interval, whereas the incidence of gastrointestinal side effects on intracervical application of PGE2 gel was only half as high and the occurrence of diarrhea significantly lower (p less than 0.05) with this non-invasive method than with intraamniotic PGF2 alpha. Intracervical PGE2 gel also possessed other advantages, being int. al. more acceptable by the patients and technically easier to administer.

Fundal contour of the uterine cavity in the new syndrome of minor müllerian anomalies and oligomenorrhea. A prospective controlled study.

A prospective, controlled, and blinded study was instituted (1) to demonstrate the relationship found previously between mild müllerian anomalies and oligomenorrhea or amenorrhea in another population of infertile or low-fertility women, (2) to substantiate and define the degree of uterine anomaly in patients with this new syndrome, and (3) to demonstrate that fundal anomalies in the patients are not secondary to mechanical trauma. Twenty consecutive patients with oligomenorrhea or amenorrhea, 44 consecutive infertility patients, and 19 patients who underwent hysterosalpingography (HSG) for other reasons made up the study group. A mild uterine developmental anomaly was demonstrated on revision of the HSG films in 50% of the patients with oligomenorrhea or amenorrhea as compared with (1) 25% of the infertility patients with normal menstrual intervals (p less than 0.05) and (2) none of the patients who underwent HSG for other reasons (p less than 0.025). The height (H) of the fundal excavation was less than 10% of the line (L) connecting the peaks of the uterine horns (H/L ratio) on all hysterosalpingograms, which gave rise to doubt whether the uterine contour was normal or abnormal. This applied to five patients with normal whether the uterine contour was normal or abnormal. This applied to five patients with mild müllerian anomalies, the H/L ratio was greater than 0.100 and the mean values for patients with oligomenorrhea and normal intervals were 0.187 and 0.165, respectively (p greater than 0.05). On this basis, it is suggested that the limit between abnormal and normal contour at HSG should perhaps be fixed at an H/L ratio of 0.100. There was no finding in the present study to indicate that the uterine anomalies were secondary to previous curettage, therapeutic abortion, operations on the uterus, or pelvic inflammatory disease.