Gestational diabetes screening in subsequent pregnancies of previously healthy patients.

OBJECTIVE: Our purpose was to evaluate women without gestational diabetes mellitus in an index pregnancy for the likelihood that gestational diabetes would develop and for risk factors for carbohydrate intolerance in a subsequent pregnancy. STUDY DESIGN: A retrospective review of medical records at a teaching hospital universally screening for gestational diabetes identified multiparous women who had been delivered twice between 1994 and 1997 and who, in the first (index) pregnancy, had had a normal result on a screening test with 50 g of glucose used in a "glucola" beverage (< or =140 mg/dL). RESULTS: In this population with normal glucose screening values in the index pregnancy, 352 (92.4%) of 381 women had at least one risk factor for gestational diabetes. However, none of the 381 women had gestational diabetes in the subsequent pregnancy (0/381, 95% confidence interval < or =1%), including 45 (12. 4%) who had an abnormal result on the 50-g glucose screening test. Regression analysis showed this test result in the index pregnancy (P =.001) to be the only studied variable significantly associated with the 50-g glucose value in the subsequent pregnancy. CONCLUSION: Despite a high rate of risk factors for gestational diabetes, women in our population with a normal glucose value in an index pregnancy have a minimal risk (<1%) that gestational diabetes will develop in a subsequent singleton pregnancy within 4 years. This factor may be included in determining whether women should undergo screening for gestational diabetes.

Hormone withdrawal symptoms in oral contraceptive users.

OBJECTIVE: To measure the timing, frequency, and severity of hormone-related symptoms in oral contraceptive (OC) users, specifically to compare active-pill with hormone-free intervals. METHODS: Using daily diaries, women recorded pelvic pain, bleeding, headaches, analgesic use, nausea or vomiting, bloating or swelling, and breast tenderness during active-pill intervals and hormone-free intervals. Participants either had no prior OC use, had taken OCs and were restarting, or had been taking OCs continuously for 12 months or longer. RESULTS: Two hundred sixty-two women, 26 with no previous OC use, 43 prior users, and 193 current users, provided daily records of hormone-related symptoms. Subjects with no prior OC use and prior users restarting were similar in no recent OC use, and because of the small sample, they were pooled for analysis as new-start OC users. Current users had patterns of symptoms that were more frequent during hormone-free intervals than during the three active-pill weeks. These included pelvic pain (70% versus 21%, P < .001), headaches (70% versus 53%, P < .001), use of pain medication (69% versus 43%, P < .001), bloating or swelling (58% versus 19%, P < .001), and breast tenderness (38% versus 16%, P < .001). Similar patterns were seen in new-start OC users after the first cycle. Among new-start OC users, menstrual flow patterns, headache, bloating or swelling, and breast-tenderness symptoms decreased during the three cycles to approach those levels of current users. CONCLUSION: Almost all symptoms assessed were significantly worse during the 7-day hormone-free interval than during the 21 days of hormone-containing pills.

Luteal phase sertraline treatment for premenstrual dysphoric disorder. Results of a double-blind, placebo-controlled, crossover study.

OBJECTIVE: To test the efficacy of late-luteal phase dosing of sertraline hydrochloride in women with moderate-to-severe premenstrual dysphoric disorder. This highly prevalent disorder often causes significant psychosocial impairment. DESIGN: Double-blind, crossover trial of each 2-menstrual cycle of baseline, sertraline treatment, and placebo. Randomization to sertraline treatment vs placebo occurred after a 2-cycle, drug-free period. SETTING: A large outpatient multispecialty clinic in central Texas. PATIENTS: Fifty-seven women aged 19 to 49 years with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of premenstrual dysphoric disorder. INTERVENTIONS: Late-luteal phase treatment with sertraline hydrochloride in daily doses of 50 mg (cycle 1) followed by 100 mg (cycle 2) vs placebo. MAIN OUTCOME MEASURES: The 22-item calendar of premenstrual experiences was completed daily and constituted the primary outcome measure, consisting of a total score and behavioral and physical factor scores. RESULTS: A repeated-measures analysis of variance for crossover designs found a significant beneficial effect from sertraline treatment in improving the calendar of premenstrual experiences total (P < .01), behavioral factor (P < .01), and physical factor (P < .04) scores. Most women improved when taking sertraline, 50 mg, although a dose increase to 100 mg yielded further improvement in approximately 25% of women. Use of sertraline was extremely well tolerated; the only adverse event reported by 10% or more of women was insomnia in 8 (14%) of them. CONCLUSIONS: Luteal phase treatment with sertraline was a safe and effective treatment for moderate-to-severe premenstrual dysphoric disorder. Further controlled studies are needed to confirm the results of this preliminary study.

Oral contraceptives: therapeutic uses and quality-of-life benefits--case presentations.

Numerous studies have shown that oral contraceptives (OC) provide protection against a wide variety of illnesses and conditions, including loss of bone density, ovarian cysts, menstrual cycle irregularities, dysmenorrhea and menorrhagia, ectopic pregnancy, pelvic inflammatory disease, benign breast disease, endometrial cancer, and ovarian cancer. How OC can be used not only for contraception but also to improve health among women throughout their reproductive years is illustrated by four case presentations: an adolescent with menstrual problems; a 25-year-old mulligravida who wishes to delay childbearing; a 35-year-old who has completed her family and requests tubal ligation; and a 45-year-old with perimenopausal symptoms. In view of their numerous health benefits, OC are to reproductive-age women as hormone replacement therapy is to menopausal women.

Efficacy and safety of a constant-estrogen, pulsed-progestin regimen in hormone replacement therapy.

OBJECTIVE: Two studies (Studies A and B) were conducted to measure efficacy and safety of constant 17beta-estradiol (E2), pulsed norgestimate (NGM) hormone replacement therapy on bleeding and vasomotor symptoms in postmenopausal women. NGM was pulsed in a 3-days-off/3-days-on fashion. Study A also assessed effects of treatment on vaginal cytology. STUDY DESIGN: In two 360-day, multicenter, double-blind, parallel-group studies, 1,253 subjects were randomized to receive daily, unopposed E2 1 mg or one of three constant estrogen, pulsed progestin regimens: E2 1 mg/NGM 30 microg, E2 1 mg/NGM 90 microg, or E2 1 mg/NGM 180 microg. RESULTS: Bleeding control improved over time in women treated with E2 1 mg/NGM 90 microg: 69% of women were free of bleeding (irrespective of spotting) during month 1, 71% during month 6, and 80% during month 12. E2 1 mg/NGM 30 microg had a lower incidence of bleeding but provided inadequate endometrial protection. Among subjects with vasomotor symptoms at baseline, the percentage of asymptomatic subjects at the end of 3 months was 70% in the E2 1-mg group and 76% in the E2 1-mg/NGM 90-microg group. E2 1 mg/NGM 90 microg was at least as effective as E2 1 mg alone in causing maturation of vaginal epithelial cells. All regimens were well tolerated. CONCLUSION: Pulsed dosing of NGM 90 microg for 3 days off and 3 days on along with continuous administration of E2 is effective in treating vasomotor symptoms and vulvovaginal atrophy, provides endometrial protection (i.e., no cases of endometrial hyperplasia or cancer), and has a bleeding profile acceptable to the majority of women studied.

Intrauterine device practice guidelines: patient types.

PIP: Currently available IUDs--the Copper T 380A and the progesterone-releasing device--may offer a viable contraceptive choice to millions of US women who have not yet found a satisfactory method. Although most IUD users in the US are 35 years of age and above, the method is appropriate for many young adults and even teenagers, provided they are in stable, monogamous relationships. Recent studies have determined that nulliparity is not a risk factor for pelvic inflammatory disease; however, both expulsion and increased menstrual bleeding and pain are more common among nulliparous women. Copper-bearing IUDs can be inserted in women who are only 4 weeks postpartum without an increased risk of perforation, expulsion, or excessive bleeding. Other candidates for IUD use include women who have undergone abortion, lactating women, perimenopausal women, those with a prior history of ectopic pregnancy, and women who cannot use oral contraception. Finally, IUDs are appropriate for women who are considering sterilization but are not yet ready to take this irreversible step. In all cases, screening for sexually transmitted disease risk factors is essential in user selection.^ieng

Cystoscopic findings consistent with interstitial cystitis in normal women undergoing tubal ligation.

PURPOSE: We test the hypothesis that women without chronic pelvic pain or irritative voiding symptoms do not demonstrate petechial hemorrhages known as glomerulations that are characteristic of patients with interstitial cystitis. MATERIALS AND METHODS: A prospective cohort design was used for examination with cystoscopy and bladder distention of 20 asymptomatic women undergoing tubal ligation. Cystoscopy with the patient under general anesthesia was performed to inspect the bladder mucosa before and after distention at 70 cm. of water pressure for 2 or 6 minutes. Photographs of the right, posterior and left of the bladder surfaces taken before and after the distention were scored on a scale of 1 to 5 using a panel of standards. Five urologists blinded to the source of individual photographs independently evaluated 120 research images interspersed with 46 other pictures from a library containing images from 19 symptomatic patients with and without interstitial cystitis. RESULTS: A total of 20 normal women with a mean age plus or minus standard deviation of 29+/-6 years consented to participate in this trial during laparoscopic tubal ligation. Photographs of bladder sites before and after distention with 890+/-140 ml. were scored as 1.4+/-0.3 (before distention) and 3.1+/-1.1 (after distention) on the scale of 1 to 5. The increase in scores following distention in normal subjects was seen to the same degree and in the same proportion as in patients with symptoms of interstitial cystitis (8 of 19 symptomatic patients in this series met current diagnostic criteria for interstitial cystitis). Slight but significant differences were seen among sites in the bladder but not between 2 and 6-minute distention durations. CONCLUSIONS: Bladder mucosal lesions characteristically associated with irritative voiding symptoms and pelvic pain in patients diagnosed with interstitial cystitis were observed in asymptomatic women.

Endometrial cancer and hormone replacement therapy. Appropriate use of progestins to oppose endogenous and exogenous estrogen.

Most instances of endometrial cancer are potentially preventable. Unopposed endogenous estrogen stimulation of the endometrium has been shown to be the predisposing risk factor in most cases. Risk factors have been well-delineated, and it is important to recognize and treat the progesterone-deficient patient. Low-dose oral contraceptive pills in healthy, nonsmoking, older reproductive-aged women are an underutilized treatment modality. The many noncontraceptive benefits of longterm oral contraceptive use until the menopause should be explained to the patient, including the prevention of ovarian and endometrial cancer, the maintenance of bone density, and a reduction in the many surgical procedures performed for menstrual disorders. Progestin therapy in older reproductive-aged women and postmenopausal women with unopposed estrogen production is mandatory to prevent endometrial cancer. Knowledge and skill in simple endometrial sampling techniques performed in patients with known risk factors for endometrial cancer will often detect premalignant lesions that are treatable with progestin therapy or surgery.

The IUD: dispelling the myths and assessing the potential.

PIP: While the IUD is the most widely used method of reversible contraception throughout the rest of the world, it is used by only 1% of women in the US. Misperceptions that inhibit use of the IUD in the US include 1) the belief that the device works as an abortifacient when, in fact, the mechanism of action of copper releasing IUDs is contraceptive; 2) the belief that all IUDs increase risk of pelvic infection when, in fact, the Dalkon shield is the only IUD associated with increased risk because its multifilament tail allowed bacteria to ascend into the uterine cavity; 3) the association of IUD usage with increased risk of ectopic pregnancy despite the evidence that copper-bearing IUDs actually reduce risk of ectopic pregnancy; and 4) fears that IUD prescribers increase their legal liability although these fears can be allayed by reviewing product information with users, obtaining their informed consent to IUD use, and documenting the provision of detailed postinsertion instructions. Both the copper-releasing and the progesterone-containing IUDs provide effective contraception associated with very low pregnancy rates. Complications of use include expulsions, which occur most frequently in the first 3 months of use and are associated with young age of the women, immediate postpartum insertion, nulliparity, and the skill of the clinician. Uterine perforation upon insertion is extremely rare, and risk depends upon clinician skill. Risk of spontaneous abortion increases if IUDs are left in place during pregnancy. The main reason for discontinuation are increased menstrual bleeding and pain in users, although the progesterone IUD is associated with reduced blood loss. Discontinuation is accompanied by a rapid return to fertility. After screening IUD candidates for risk factors, insertion can occur at any time as long as pregnancy is ruled out (with postpartum insertion recommended after 4 weeks). Users should receive detailed instructions about how to check for expulsion. IUDs provide a good longterm alternative to sterilization.^ieng

Extending the duration of active oral contraceptive pills to manage hormone withdrawal symptoms.

OBJECTIVE: To test the hypothesis that extending the number of consecutive active oral contraceptives (OC)s given will decrease the frequency of menstrual-related problems including dysmenorrhea, menorrhagia, premenstrual-type symptoms, and menstrual migraines. METHODS: A prospective analysis was designed to track the experiences of 50 women taking OCs and experiencing menstrual-related problems. Fifty consecutive patients, who were taking OCs and had symptoms during the pill-free interval, were followed in a multispecialty clinic by an individual physician and nurse practitioner team. The patients were permitted to extend the number of consecutive active OCs to delay menstrual-related symptoms. RESULTS: Immediate outcome of the 50 patients revealed 74% (37 patients) stabilized on an extended regimen of 6 to 12 weeks of consecutive days with active OCs. Twenty-six percent (13 patients) either discontinued OCs or returned to the standard regimen with 3 weeks of active pills. Of the 37 patients who were stabilized on an extended regimen, 27 have completed thus far between five and 13 extended cycles with 6-23 months of follow-up (mean 16 months). CONCLUSIONS: Experience in a series of 50 OC users with menstrual-related symptoms demonstrated that delaying menses by extending the number of consecutive days of active pills is well tolerated and efficacious. We believe that a large prospective study is warranted to further our knowledge in this area.

Evaluation of 3-Day Course of Doxycycline for the Treatment of Uncomplicated Chlamydia trachomatis Cervicitis.

OBJECTIVE: The purpose of this study was to compare the efficacy of a 3-day course of doxycycline to a standard 7-day course for treating uncomplicated chlamydia cervicitis. METHODS: During an 18-month period, 77 women with uncomplicated chlamydia cervicitis were randomized to receive either a 3-day or a 7-day course of doxycycline (100 mg twice daily). Tests of cure were performed 3 weeks after completion of therapy with the Amplicor polymerase chain reaction (PCR) assay (Roche Molecular Systems, Branchburg, NJ). Demographics, therapeutic results, and side effects for the two groups were compared. RESULTS: Seventy-three patients completed the study: 35 in the 3-day group and 38 in the 7-day group. There were no significant differences in age, gravidity, or parity between the groups. There was a 94% (33/35) cure rate in the 3-day group and a 95% (36/38) cure rate in the 7-day group (P = 1.0). Thirty-four percent and 32% of the patients in the 3- and 7-day groups reported side effects, respectively; there was no significant differences between the 3- and 7-day groups in regard to population demographics, patient compliance, therapeutic outcome, or side effects. CONCLUSIONS: A 3-day course of doxycycline appears to be as effective as a 7-day course of doxycycline for the treatment of uncomplicated chlamydia cervicitis.

Practice guidelines for OC selection: update.

PIP: This report updates practice guidelines for oral contraceptive (OC) selection developed by US clinicians and researchers in 1996 on the basis of clinical experience, expert opinion, and a review of the research literature. The update was necessitated by the availability of new OC formulations, increased awareness of the range of noncontraceptive benefits of OCs, and emerging evidence linking OCs to cardiovascular and breast cancer risks. To facilitate the review, available OCs are categorized on the basis of low, medium, or high androgenic activity of the progestin component. Overall, the report recommends OC use as a first-choice method unless a woman has a clear contraindication, suffers intolerable side effects despite changes in the type of progestin or dose, or has difficulty taking the tablets consistently. Tables included in this report present the estrogen and progestin doses in all OCs currently available in the US; set forth guidelines for OC selection for different categories of women (e.g., adolescent, postpartum, perimenopausal) and to minimize OC-related side effects and adverse health effects; and offer recommendations to guide the formulation selection in women with pre-existing medical conditions, menstrual disorders, and other reproductive health problems.^ieng

Practice guidelines for OC selection.

PIP: Clinical practice guidelines are important to clarify the potential risks, benefits, and costs of available interventions. Although oral contraceptives (OCs) are the most popular reversible method of fertility control in the US, there are at present no evidence-based guidelines for OC selection. Toward this end, members of the Editorial Board of "Dialogues in Contraception" met to develop initial guidelines for OC selection that reflected both a reasonable interpretation of the available literature and the authors' clinical experiences. Today's OCs contain differing types and doses of estrogen. The central principle in OC prescribing should be that the formulation selected contains the least amount of estrogen and progestin that is possible given the patient's needs. These guidelines divide available OCs into categories of low, medium, and high androgenic activity of the progestin component. The low androgenic progestin-containing OCs are associated with reduced side effects, improved cycle control, improved lipoprotein profile, and enhanced tolerability. Included with the guidelines are tables that classify OCs by their composition, identify OCs with the potential to minimize or manage unwanted side effects, recommend formulations for women with medical conditions, and outline use of OCs for the treatment of gynecologic symptoms.^ieng

The perimenopause: a critical time in a woman's life.

The interval from the initiation of declining estrogen levels to final ovarian failure usually encompasses many years. The age of onset and duration of this perimenopausal time can vary greatly. While many patients may have minimal to no symptoms as estrogen levels first begin to decrease, most patients will eventually develop symptoms and sequelae as they approach ovarian failure. The consequences of this decline in ovarian function are numerous, and include vasomotor symptoms, declining bone mass, urogenital changes, infertility, irregular uterine bleeding, and psychosexual dysfunction. The women of today entering the perimenopausal period are unique because of their vast numbers, a consequence of the aging of the "baby boomers." Their reproductive history is also different from that of their ancestors in that many have chosen to delay childbearing into their thirties and even forties, and many have elected not to have children. Because of the unique characteristics of this extremely large population of women that are approaching or currently in the perimenopausal period, it is vital that healthcare providers fully understand the variability, consequences, and treatment modalities of this time of declining ovarian function. Risk factors for such common health problems as osteoporosis, heart disease, and cancers must be assessed and managed appropriately. Screening tests including mammography and cholesterol profiles should be offered along with dietary and exercise recommendations. Low-dose oral contraceptive pills and hormone replacement therapy are often effective in preventing and treating many of the common problems encountered during the perimenopausal period.

Contraception in the later reproductive years: a valid aspect of preventive health care.

PIP: Women 30 years or older have 4 reversible contraceptive methods that are at least as effective as sterilization: oral contraceptives (OCs), the IUD, Norplant implants, and the injectable, Depo-Provera. Physicians have not done a good job educating women about these contraceptive options. 80-95% of women do not know about the key noncontraceptive benefits of OCs. Women delay childbearing longer than did their predecessors. Women who have completed their families and have not reached menopause face 4 key issues about contraceptive selection: risk for unplanned pregnancy, increase in incidence and severity of many gynecologic problems (e.g., irregular bleeding), increased risk of breast cancer and/or ovarian and endometrial cancers; and reduced bone mass with decline in ovarian function. Each woman of advanced reproductive age should be fully aware of all contraceptive options, the benefits and risks linked to each, and the effect of each on her future health, when she chooses her own contraceptive method. Women in their late 20s or early 30s who are not 100% sure that they do not want anymore children should not choose tubal sterilization because it is more or less permanent. Physicians should provide to women considering sterilization information about reversible methods as well. Healthy, nonsmoking women over 40 can safely use OCs. They also derive noncontraceptive health benefits from OC use, e.g., reduced incidence of endometrial and ovarian cancers and of severe rheumatoid arthritis and good menstrual cycle control. The IUD is an option for smokers 35 and older. A copper IUD can be used for up to 10 years. Long-acting progesterone methods (implants and injectables) are linked to an increase of clinical side effects. Depo-Provera is associated with a reduced risk of endometrial cancer. Motivation is required for condom use and periodic abstinence.^ieng

Vaginal pessaries and their use in pelvic relaxation.

To evaluate the therapeutic usefulness of pessaries in patients with pelvic relaxation, a retrospective study was performed identifying 107 patients who had been fitted with a pessary for symptomatic pelvic relaxation. Of this group, 101 returned or were available for follow-up. Ninety-one had at least one pelvic organ protruding to or beyond the hymen. Specific reasons for using the pessary are cited. Group 1 included 19 patients who were thought to be medically unfit for surgery. Twenty-one percent of this group died within one year of their evaluation for pelvic relaxation. Group 2 was composed of 24 patients who chose to use the pessary only temporarily while awaiting a suitable time for surgery. Group 3 consisted of 58 patients who were offered the option of definitive surgical repair but initially declined. Fifty of the 101 patients have continued to use the pessary. Twenty-six had repairs, and four have died. Only 21 patients have discontinued the pessary, had no surgical repair and thus continue without treatment of their pelvic relaxation. No major complications were associated with use of the pessary.

Unwanted pregnancies: understanding contraceptive use and benefits in adolescents and older women.

The highest percentages of unintended pregnancies and the largest increases in births reported in the United States in recent years were in adolescents and in women more than 35 years of age. Increasing numbers of these women will require contraception to avoid unintended pregnancy. In adolescents the combined oral contraceptive agents protect fertility indirectly and exert favorable actions on menstrual dysfunction and certain hormone-related disorders such as acne and hirsutism. To avoid sexually transmitted disease, barrier protection should be used along with oral contraceptives until mutually monogamous, stable relationships are established. Healthy older women who are nonsmokers may also safely use currently available contraceptives. These agents have little impact on metabolic parameters linked to the development of cardiovascular disease. In addition to providing reliable contraception, oral contraceptives offer noncontraceptive benefits to older reproductive-age women, including control of abnormal bleeding and a reduction in the incidence of ovarian and endometrial cancers and other gynecologic pathology. Intrauterine devices and progestin implants are safe, effective, and underused in the United States. Progestin implants may have an additional role in patients for whom estrogen preparations are contraindicated. Counseling is very important before insertion because of the high rate of nuisance side effects. The contraception selection process must consider the efficacy and acceptability of the specific method to avoid the probability of unintended pregnancy and the risk of sexually transmitted diseases.

Performance of the syva direct fluorescent antibody assay for Chlamydia in a low-prevalence population.

Chlamydia trachomatis is the most common reportable sexually transmitted disease (STD) in the United States. In the 1980s, rapid diagnostic tests for chlamydia began to replace more cumbersome tissue culture methods. Current data on rapid antigen detection assays demonstrate acceptable sensitivity, specificity, and predictive values in populations with a high prevalence of chlamydia. Few studies report the performance of these assays in a low-prevalence obstetric and gynecologic (Ob/Gyn) population, This study compares the most commonly used direct fluorescent antibody (DFA) assay (Syva Microtrak) with tissue culture (TC) in a low-prevalence population. Endocervical specimens (775) were tested from women at risk for chlamydia infection, and the prevalence was found to be 7.7%. The DFA assay demonstrated a sensitivity of 80% and a specificity of 97% compared with TC. The positive and negative predictive values were 72% and 98%, respectively. The results of this study indicate that the Syva DFA assay lacks the sensitivity and positive predictive value for routine use in Ob/Gyn populations with a lowprevalence of C. trachomatis.

Resident research in obstetrics and gynecology: development of a program with comparison to a national survey of residency programs.

OBJECTIVE: The objective of this report is to describe our recently established resident research program and to compare this program with those of other obstetrics and gynecology residency training programs in the United States. STUDY DESIGN: The components of our program are described. Data for comparison from other programs were obtained from questionnaires, phone follow-up and the Directory of Obstetrics and Gynecology Residency Programs of the Council on Resident Education in Obstetrics and Gynecology. RESULTS: We initiated a residency research program in 1987 with acceptable projects defined, a time for completion of manuscripts established, and a Resident Research Day organized with presentation of articles, critique by a guest speaker, and an awards banquet. Nationally, less than 60% of residency programs have research requirements. Of the 208 programs responding to the written questionnaire 86% of programs associated with a university required research compared with 10% of community-based residency programs. CONCLUSION: While more than a third of residency programs in obstetrics and gynecology do not have resident research programs, the trend is for programs to establish research as a required portion of training. An outline of a recently established program is provided.