[Juvenile Parkinson's disease and recurring prematurity. Case report]. / Maladie de Parkinson juvénile et prématurité récidivante. A propos d'un cas.

The association of Parkinson's disease and pregnancy is very rare. Some thirty cases are found in the literature. We report the case of a pregnancy in a 30-year-old patient with juvenile Parkinson's disease. During this pregnancy treated by levodopa and bromocriptine, no aggravation of the symptoms was been observed. However, the pregnancy was complicated by a premature delivery at 31 weeks of amenorrhoea.

[A pregnant woman with a SAPHO syndrome]. / Grossesse chez une patiente présentant un syndrome de SAPHO.

The association SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) and pregnancy is very rare. Only one case is indexed in the literature. We report the case of a pregnancy in a 27-year-old patient with a SAPHO syndrome and we expose its history and its obstetrical, medical and anaesthetic following. Under this multi-field following, there was no evolutionary push of the disease neither during the pregnancy, nor in immediate postpartum. We will expose the different possible treatments during the pregnancy.

[Smoking and pregnancy: survey among women enrolled in an independent worker insurance program]. / Tabac et grossesse. Etude de l'Assurance maladie des professions indépendantes en Ile-de-France.

OBJECTIVES: In order to further improve its prevention program entitled "Maternity childhood follow-up", the Paris region health insurance program for independent workers carried out a survey among female participants. The survey was designed to assess women's smoking behavior and evaluate reception of information concerning smoking-related risks and support available to stop smoking. The women's suggestions were also collected. MATERIALS AND METHODS: A questionnaire was sent by the physicians in charge of the Ile de France region to the 3525 women who had reported a pregnancy. RESULTS: 1099 answers were received (31%) The mean age of responders was 34.3 4.7 years. Their educational level was high (76% had a university degree). Before pregnancy, 37% were smokers. At the first trimester of pregnancy, 17% were smokers, 15% at the second trimester and 14% at the third trimester. Two years after childbirth, 20.5% were smokers. The proportion of women who stopped smoking was higher for those with a low Fagerström score. 29% of women said they did not receive any information about the harmful consequences of smoking. To cease smoking during pregnancy, 70% are helped by family and friends, 20% by health professionals; 3.5% took nicotine substitutes. CONCLUSION: This survey emphasises the need for improving information to pregnant women for alerting them to the dangers of smoking and for training the relevant health professionals.

The Coraliance study: non-compliant behavior. Results after a 6-month follow-up of patients on oral contraceptives.

OBJECTIVES: This follow-up study was planned to establish the frequency with which women miss their contraceptive pill, and to observe their behavior when they forget it. In those women who changed from a continuous cycle to an interrupted type of cycle, or vice versa, the study also aimed to evaluate the impact of this change on the pattern of omission of pills. METHODS: The longitudinal, prospective cohort study included healthy women of child-bearing age for whom a change of pill was being prescribed by their gynecologist. Data were recorded during the 6 months preceding inclusion in the study, and for the 6 months of follow-up; the women were asked to complete a diary in which they recorded the number and exact times of pill omission, and their behavior at each omission. RESULTS: A total of 617 gynecologists included 3316 women into the study; of these, a group of 2418 (73%) revisited the same gynecologist at follow-up. The groups who either visited the same or a different gynecologist were similar with respect to age, oral contraception type, omission type and frequency. A large non-compliance rate and women's difficulties in maintaining safe contraception after missing a pill were observed in the group with follow-up. Women were never risk-free when they missed a pill; they turned to numerous sources for discordant or conflicting information; 15% of 'not-forgetting' women at the pre-inclusion cycle recorded at least one omission at the last cycle of the 6-month follow-up period. Omission fluctuations during the observational period make it difficult to designate 'forgetful' or 'non-forgetful' classes of women. Administration of the pill in a continuous cycle, and probably 'study' and 'auto-questionnaire' effects, contributed to an improvement in compliance. In the group taking the continuous cycle pill, the omission number slightly decreased, particularly on the first day and week of the cycle, irrespective of the initial cycle type. CONCLUSIONS: The importance of the phenomenon of non-compliance rate is confirmed as well as women's difficulties in knowing how to maintain contraceptive safety. The continuous cycle regimen is likely to improve women's compliance during the critical period of the cycle.

The acceptability of a small intrauterine progestogen-releasing system for continuous combined hormone therapy in early postmenopausal women.

OBJECTIVE: To assess the acceptability, ease of insertion, tolerance and associated bleeding of a novel intrauterine progestogen-releasing system, combined with transdermal estradiol, in postmenopausal women. DESIGN: An open non-comparative study of 294 postmenopausal women with an intact uterus at 27 centers in six countries. METHOD: All subjects had requested treatment for menopausal symptoms and had received transdermal estradiol 50 microg/day by patch and an experimental intrauterine system (MLS) releasing levonorgestrel 10 microg/day. Details of the insertion were recorded and subsequent bleeding, side-effects and adverse events were documented on a daily diary. Endometrial thickness was measured by transvaginal ultrasound scan prior to insertion of the MLS and after 12 months. The study is of 3 years duration. This report summarizes the results after the first year. RESULTS: The median age of the subjects was 52.6 years (range 41.7-59.6 years), 90% were within 3-5 years of menopause and 78% had previously used hormone therapy (HT). The MLS was inserted at the first attempt in 297/294 (94%) subjects and was facilitated by dilatation of the cervical canal in 65 (22%) subjects. Local anesthesia was given to 30 (10%) subjects. Of the 17 with a failed first insertion, two subjects did not want a second attempt, in 14 a second attempt succeeded, facilitated by cervical dilatation in seven and local anesthetic in three subjects. There was one failed insertion. Investigators rated 80% of first insertions as easy, 14% as slightly difficult and 6% as very difficult. The second insertion was easy in 9/15 subjects, slightly difficult in 4/15 and very difficult in one (data from one subject missing). During insertion, 34% subjects had no pain, 49% said it was mild, in 15% it was moderate and in 2% the pain was severe. At 12 months, one MLS had been expelled. Spotting was the most common form of bleeding and this decreased from a median of 9 to 0 days at 4 months, although 10% of subjects continued to report spotting up to 12 months. Bleeding days were few and mainly in the first 2 months. At the end of month 11, 66.8% were amenorrheic and 87% non-bleeding. Only nine subjects discontinued because of bleeding. There was no correlation between the bleeding profiles and number of years since menopause, previous HT use or body mass index. The median endometrial thickness at entry to the study (without HT) was 2.6 mm and 3.4 mm at 12 months. Of the adverse events, after the pain associated with insertion, headache was the next most common at 13.3% and mastalgia was experienced by 7.8% of subjects. Overall, the dropout rate was low at 28 subjects (9.5%). There were favorable changes in the serum lipid profile consistent with the effects of estradiol and suggesting minimal attenuation by the intrauterine progestogen. Conclusion This interim report of a 3-year study has confirmed that the menopausal levonorgestrel intrauterine system is easy to insert and is well tolerated by postmenopausal women.

[Effects of a 19-norprogesterone derivative, the fourth decade nomegestrol acetate, on lipids]. / Effets sur les lipides d'un progestatif 19-norprégnane. Le nomégestrol acétate.

Dyslipidemia is a cardiovascular risk factor which commonly develops during forty. In Europe, progestins are frequently prescribed for treatment of perimenopausal symptoms in women in this age group, as well as in combination with estrogen replacement therapy in non hysterectomised postmenopausal women. Their complete metabolic tolerance is an important, even if non exclusive, factor to take in consideration for cardiovascular protection. Our aim was to review available data on the effects of a 19-norprogesterone derivative, nomegestrol acetate, on lipid tolerability. In healthy or at risk premenopausal women, clinical studies found no significant changes in lipid parameters (total, HDL and LDL cholesterol, triglycerides, apoprotein B, Lp(a) and LpA-I) with nomegestrol acetate administered in antigonadotropic sequence, alone or combined with estrogen in inverse sequence, during 6 to 9 cycles; there was only a small statistically significant decrease in apoprotein A1, probably due to the induced hypoestrogeny. In clinical studies carried out in postmenopausal women, nomegestrol acetate combined with estrogen replacement therapy in a sequential or continuous combined regimen, did not alter the beneficial estrogen-induced lipid profile: reductions in total and LDL cholesterol, apoprotein B and Lp(a); HDL cholesterol was unchanged and an increase in triglycerides occurred only with oral estrogens. A decrease in apoprotein A1 was found after six months of a cyclic sequential hormone replacement therapy but was associated with a beneficial increase in LpA-I. Nomegestrol acetate has proven its neutral effects on lipid metabolism and does not alter the beneficial estrogen-induced lipid effects.

Oral contraception: patterns of non-compliance. The Coraliance study.

OBJECTIVES: To determine the number of times women failed to take their oral contraceptive medication and their behavior in response to a missed pill. Another objective was to determine the potential benefit provided by a continuously administered oral contraceptive compared with an oral contraceptive involving a pill-free interval during a 6-month period. METHODS: Healthy women were enrolled in a cohort study; their contraceptive practices were followed by their gynecologists. Data were collected at inclusion using cross-sectional method with retrospective data collection for the previous 6 months and, more specifically, on their previous or their current menstrual cycle. Women on the pill were asked to specify the number of times and precise time at which they missed one or more pills and what they did in response to missing a pill. RESULTS: A total of 617 gynecologists enrolled and followed 3316 patients from six geographic areas throughout France. The mean age of patients was 30 years. Duration of oral contraceptive use was 8 years. During their previous cycle, 23% of women (n = 737) missed a pill at least once. Among women on the pill involving a treatment-free interval, 42% of instances of missing a pill occurred during the first week following the treatment-free interval. In response to missing a pill, patients read the product information leaflet (39%) or asked someone's advice (28%), mainly their gynecologist (63%) or their family physician (18%). Almost one-third of women did not take any specific measures. CONCLUSIONS: Patients on a discontinuous oral contraceptive regimen tended to miss a pill during the first week of treatment. Prescription of a continuous regimen without a treatment-free interval may improve compliance.

[Compliance with hormone replacement therapy in menopause: effect of an original education program. The COMET study]. / Observance du traitement hormonal substitutif de la ménopause: effet d'un programme d'éducation original. L'étude COMET.

OBJECTIVE: To study the impact of an original education program on compliance to hormone replacement therapy (HRT) in post-menopausal women. METHODS: Data were obtained from 1,192 post-menopausal women (age: 53 +/- 5 years) included in the study with an onset less than six months: E2 gel (n = 791) or patch (n = 401) + progestins, and randomized in either educational program (Ep = 600) or regular verbal counselling (VC = 592). A patient is considered bad compliant with HRT when she prematurely stopped the study, whatever the reason of the cessation. The groups EP and VC are homogeneous for the age distribution, the HRT regimen, the date of onset and the climateric symptoms scores. RESULTS: There is a significant difference between EP and VC groups in compliance, respectively 86 and 81% (p < 0.027). This difference is partially explained by the significant improvement in the patch subgroups (EP: 86% versus VC: 77%, p = 0.028). The trend observed in the gel group is not significant (EP: 85% and VC: 82%) due to the high level of compliance usually noticed in women treated with the gel and the verbal counselling. The significative difference in the compliance observed during the verbal counselling between the continuous (76%) and the sequential (86%, p = 0.001) HRT regimen disappears with the educational program (continuous: 84% and sequential: 87%, NS). CONCLUSION: This first large study on the HRT compliance in France, using a patient educational material, validates its efficacy to reach a better compliance than with regular verbal counselling. Even though in the daily practice, about 40% of the patients discontinue the treatment during the first year, 81% of the women followed in this study continue to receive the HRT after nine months of use. The original educational program of the COMET study improves significatively this high compliance (+ 5% from the verbal counselling). Thus, the combination of the doctor verbal counselling and an educational material is desirable to obtain a good compliance with HRT.

[Acute pelvic pain in women]. / Douleurs pelviennes aiguës chez la femme.

Acute pelvic pains in women can reflect highly diverse disorders of varying severity, sometimes requiring surgery. It thus is clearly a part of abdominal emergencies in the adult. Good knowledge of underlying gynaecological disorders usually avoids unnecessary surgery. The use of echography has greatly contributed to reducing coelioscopy for diagnosis.

Local spermicidal contraception: a comparative study of the acceptability and safety of a new pharmaceutical formulation of benzalkonium chloride, the vaginal capsule, with a reference formulation, the pessary.

OBJECTIVE: To evaluate comparatively the acceptability and safety of a new pharmaceutical form of benzalkonium chloride, the vaginal capsule, with the pessary form. METHODS: Eighty-nine women were randomized to receive either a benzalkonium chloride vaginal capsule or a benzalkonium chloride pessary prior to sexual intercourse according to an open cross-over design over a 2-month study period. RESULTS: The discomfort caused by delayed leakage or discharge was mild. The mean scores for subjective signs (burning, itching, vulvar pruritus) were also mild and were comparable for the two formulations. The capsule appeared to be slightly superior to the pessary regarding discomfort caused by immediate discharge or leakage, ease of use and acceptance by the woman's partner. Local safety was generally good. Adverse events consisted chiefly of vulvar pruritus and a vaginal or vulvar burning sensation, with a higher incidence being associated with the pessary than the capsule. All symptoms regressed spontaneously after the end of treatment. CONCLUSIONS: This study demonstrated good acceptability and good local safety for the benzalkonium chloride vaginal capsule. It is essential to take these parameters into consideration in the evaluation of any local spermicidal contraceptive, since they play a large part in compliance with, and thus in the efficacy of, the product under assessment.

Clinical equivalence of intranasal and oral 17beta-estradiol for postmenopausal symptoms.

OBJECTIVE: The aim of this study was to demonstrate clinical equivalence between a novel intranasal estradiol formulation and a reference oral drug. STUDY DESIGN: In this multinational, double-blind, parallel-group study 659 postmenopausal women with moderate to severe postmenopausal symptoms were randomly assigned to receive either 300 microg/d intranasal 17beta-estradiol (S21400) or 2 mg/d oral micronized estradiol, plus the appropriate placebo, for 24 weeks. All patients also received 10 mg/d dydrogesterone for 14 days per 28-day cycle. Adjustment of intranasal dosage was permitted from week 14 on. The primary efficacy criterion was the Kupperman index at week 14, with a predefined limit of equivalence of 4. RESULTS: Kupperman index scores improved similarly in the 2 groups, from 28.4 +/- 6.2 to 10.0 +/- 8.6 (mean +/- SD) for S21400 and from 28.1 +/- 6.0 to 8.9 +/- 8.0 for oral therapy, with a difference between groups at week 14 of 1.1 +/- 0.6 (90% confidence interval, 0. 0 to 2.2). This was below the predefined equivalence limit of +4 for statistical noninferiority (P <.001). The daily number and intensity of hot flushes decreased similarly in the two treatment groups. Withdrawal bleeding was 20% less frequent with intranasal therapy (90% confidence interval, 12.5 to 27.6). Severe mastalgia was less frequent in the S21400 group (1.0%) than in the group with oral therapy (5.2%; P <.01). Triglyceride and angiotensinogen levels increased significantly with oral therapy but not with S21400. The same number of patients required dose adaptation in the 2 groups (approximately 20%). CONCLUSION: Intranasal administration of 300 microg/d estradiol was at least as effective as oral administration of 2 mg/d estradiol in alleviating postmenopausal symptoms, with less frequent mastalgia and uterine bleeding and without the metabolic consequences of the first-pass effect.

[An MRI study of the normal pelvis in the immediate postpartum period]. / Etude IRM du pelvis normal en post-partum immédiat.

PURPOSE: To describe the MR findings of the pelvis in the early post-partum period, after vaginal delivery or cesarean section. MATERIALS AND METHODS: Fifteen asymptomatic patients were imaged using a 1.5 Tesla MR unit between 1 and 7 days following delivery. Eight patients had a vaginal delivery, and seven patients had a cesarean section. RESULTS: The following items were evaluated: uterus size, architecture, and contents; uterine and abdominal wall scars; parametrium; peritoneal cavity; ovarian veins. CONCLUSION: MRI provided a good evaluation of the pelvic changes related to pregnancy and delivery. Knowledge of the normal findings should improve diagnosis of early post-partum complications.

[Influence of nomegestrol acetate on the improvement of the quality of life induced by estrogen therapy in menopausal women]. / Influence de l'association du nomégestrol acétate sur l'amélioration de la qualité de vie induite par une estrogénothérapie chez la femme ménopausée.

Estrogen replacement therapy in postmenopausal women is followed by several benefits including a prompt improvement of quality of life. Due to uterine proliferation induced by prolonged estrogen intake, progestogens are usually associated, on a cyclical basis, in hormonal replacement therapy prescribed to non-hysterectomized women. Persistence of the beneficial effect of estrogen on quality of life, during progestogens intake, was never investigated. We evaluated, through a specific and previously validated questionnaire, the changes in quality of life observed in 351 women recently menopaused, after 6 months of hormonal replacement therapy associating 24 days of estrogens and 12 days of administration of a non androgenic progestogen: nomegestrol acetate. Patients were randomized within two therapeutic groups in which evaluation of quality of life was performed either during the administration of estrogen alone or during administration of estrogen and progestogen. In the two groups, hormonal replacement therapy was followed by a significant improvement (P < 0,001) in quality of life and no significant difference was observed between the changes observed during estrogen or estrogen-progestogen administration. Quality of life indices measured after 6 months of hormonal replacement therapy are within the same range than values previously described in eugonadal women. We conclude that improvement of quality of life induced by estrogen replacement therapy remains unchanged during cyclical administration of nomegestrol acetate.

Maternal serum human chorionic gonadotropin level at fifteen weeks is a predictor for preeclampsia.

OBJECTIVE: Our purpose was to study the correlation between maternal serum human chorionic gonadotropin levels measured at 15 to 18 weeks of amenorrhea and pregnancy-induced hypertension, preeclampsia, and small-for-gestational-age neonates. STUDY DESIGN: Prospective trisomy 21 human chorionic gonadotropin screening data from 5776 patients were examined in a retrospective investigation of the relationship between human chorionic gonadotropin and pregnancy-induced hypertension (234 cases), preeclampsia (34 cases), and small-for-gestational-age neonates (238 cases). RESULTS: Maternal serum human chorionic gonadotropin (multiples of the median) was higher in the three populations with pathologic disorders. This difference was statistically significant in patients with small-for-gestational-age neonates (p < 0.0163) and preeclampsia (p < 0.0001) but not in those with pregnancy-induced hypertension. In the preeclampsia subgroup, with a cutoff value of 2 multiples of the median, specificity was 32% and sensitivity was 10%; with a cutoff value of 1 multiples of the median, specificity was 100% and sensitivity was 50%. CONCLUSION: High maternal serum human chorionic gonadotropin levels at 15 weeks are related to a risk for preeclampsia. Depending on the human chorionic gonadotropin cutoff value, 32% or 100% of preeclampsia patients would be selected. The usefulness of preventive aspirin treatment from the fifteenth week needs more investigation in a larger multicenter study of preeclampsia.