The pelvic pain syndrome.

PIP: Physicians are beginning more and more to understand pelvic pain syndrome (PPS). Transuterine pelvic venography shows that some women who suffer from chronic pelvic pain have moderate or severe congestion. On the other hand, laparoscopy indicates that some cases have no physical abnormalities. A psychological component is frequently involved, but automatically referring a woman with PPS to a psychiatrist is unproductive. Instead, physicians should involve a psychologist based at a gynecologic clinic, especially in the case of women with a history of sex abuse with a high somatization score. In the case of women who suffer from PPS but clearly show no apparent physical causes, physicians should not investigate any further, but instead reassure them. Reassurance usually results in alleviation of pain within 6 months. PPS only strikes premenopausal women, suggesting that ovarian activity may also be involved. Thus, treating women with hormones to suppress ovulation benefits some women. The medical community still does not know whether longterm treatment with gonadotropin-releasing hormone analogues and hormone replacement effectively eliminates pelvic pain. If the above treatments do not successfully treat PPS, physicians can perform a hysterectomy and bilateral oophorectomy and prescribe sufficient hormone replacement therapy to remove heretofore undetected disease (e.g., ovarian cysts, adenomyosis, and fibroids) in 33% of cases of idiopathic PPS and alleviate pelvic pain in 66% of such cases.^ieng

Contraceptive problems in the developed world.

In most developed countries contraception is available and relatively cheap. In Britain 50% of women use reversible contraception and over the age of 35 more than 50% of women (or their partners) have been sterilised. Nevertheless large numbers of unplanned pregnancies still occur in all countries. Annual abortion rates (per 1000 women aged 15-44) are 5.6 in the Netherlands, 13 in Britain and 28 in the USA. In Britain about 50% of all conceptions are unplanned. Ambivalent attitudes to sex mean that there is inadequate public discussion about contraception. The media publicise adverse effects of oral contraceptives more than their benefits. Advertising of condoms is restricted, and the marketing of oral contraceptives to doctors emphasizes their side-effects. Contraception should be made more accessible to potential users, particularly the young, who are at greatest risk of unwanted pregnancy. Opinion among teenagers and their parents is in favour of more sex education at school. Efforts should be directed towards providing young people with better education on sex and contraception.

The effect of delayed pushing in the second stage of labor with continuous lumbar epidural analgesia.

We studied primigravid women in spontaneous labor at term and given epidural analgesia. Two hundred such women giving birth in 1983 were compared with similar groups who gave birth in 1985 and 1987 after the introduction of 'delayed pushing' into our labor ward protocol. Four hundred controls were obtained in 1983 and 1985 by selecting from the labor ward register the next normal primigravid woman in spontaneous labor without epidural analgesia. The assisted delivery rate was significantly higher in all three epidural groups than in the controls (p less than 0.001). Among epidural labors, there was no significant difference between 1983 and 1987 in the incidence of rotational or non-rotational forceps, or of cesarean section. In each epidural group, women who waited more than 60 min were less likely to experience a normal spontaneous delivery than were those who did not (p less than 0.001 in 1983; p = 0.006 in 1985 p = 0.035 in 1987). We conclude that to delay pushing beyond 60 min confers no benefit regarding mode of delivery.

Secretory proteins of the endometrium--potential markers for endometrial dysfunction.

In contrast to our detailed knowledge of endometrial structure, the study of endometrial function is still in its infancy. It seems likely that most of the changes that occur in the endometrium during the cycle are directed towards the promotion of implantation, and that the proteins secreted by the tissue have a role to play in the maintenance of pregnancy. One approach to the study of these proteins has been the incubation of endometrium in vitro with labelled amino acid precursors, and this method has revealed that in early pregnancy two proteins are quantitatively more important than the others synthesized and secreted by the endometrium. One of these proteins is a homologue of beta-lactoglobulin, also known as alpha 2-PEG, PP14 or PEP. It is synthesized by endometrial glands and no other source has been identified. Its synthesis is induced in the luteal phase of the menstrual cycle, rises to a peak in the early weeks of pregnancy and then rapidly declines as the decidua spongiosa is replaced by decidua compacta. The direction of its secretion appears to be into the amniotic fluid, and its function may be to transport a vitamin or other essential substance to the early conceptus: another possible function is immunosuppression. The protein can be measured in peripheral blood and may be useful as a marker of the effect of progesterone-or its lack of effect, as in the inadequate luteal phase. The other quantitatively important endometrial protein is IGF binding protein, which is produced mainly by stromal fibroblasts in the late luteal phase of the cycle. During the cycle the contribution of the endometrium to serum levels of IGF-BP is slight, but in pregnancy, as the amount of decidua compacta increases, levels in peripheral blood rise, with peaks at 18-24 weeks and at 36-40 weeks. The function of the protein may be to protect the mother by inhibiting IGF, or to enable IGF to stimulate the growth of endometrial stroma. Links between this protein and disorders of fetal growth have been suggested. The diversity of the possible functions of these proteins, and the continuing uncertainty over their roles, underline the complexity of endometrial functions.(ABSTRACT TRUNCATED AT 400 WORDS)

The contraceptive pill and breast cancer in young women.

PIP: As more epidemiological studies are done on the effect of oral contraceptives (OCs) on breast cancer, the more unclear the effects are. On the other hand, 9 case control studies demonstrated that combined OCs reduce the risk of endometrial cancer, and 8 case control studies showed a reduced risk of ovarian cancer. It is biologically plausible for there to be a protective effect against these 3 cancers, but as for breast cancer, it is not yet known if combined OCs enhance or antagonize harmful effects of ovarian activity. Researchers conducted a case control study in 11 areas of the United Kingdom consisting of 755 women with breast cancer that had been diagnosed before the age of 36 years. They found an association between the duration of use of combined OCs and the risk of breast cancer (relative risk of 1.74) after 8 years of using combined OCs. The significance of this study was that the association was noted whatever the age at which the combined OCs were taken and was noted both before and after the 1st full term pregnancy. Another new finding included an apparent link between cancer risk and the dose of estrogen: those combined OCs with 50 ug ethinyl-estradiol carried less of a risk, yet some risk was still detectable with low dose pills. Since the researchers restricted the study to women 36 years old, the results may not be relevant to most women with breast cancer, however. Further, the authors of this study bring to the reader's attention that the national breast cancer registration rates are not increasing. This is indeed reassuring.^ieng