Lifestyle and metabolic approaches to maximizing erectile and vascular health.

Oxidative stress and inflammation, which disrupt nitric oxide (NO) production directly or by causing resistance to insulin, are central determinants of vascular diseases including ED. Decreased vascular NO has been linked to abdominal obesity, smoking and high intakes of fat and sugar, which all cause oxidative stress. Men with ED have decreased vascular NO and circulating and cellular antioxidants. Oxidative stress and inflammatory markers are increased in men with ED, and all increase with age. Exercise increases vascular NO, and more frequent erections are correlated with decreased ED, both in part due to stimulation of endothelial NO production by shear stress. Exercise and weight loss increase insulin sensitivity and endothelial NO production. Potent antioxidants or high doses of weaker antioxidants increase vascular NO and improve vascular and erectile function. Antioxidants may be particularly important in men with ED who smoke, are obese or have diabetes. Omega-3 fatty acids reduce inflammatory markers, decrease cardiac death and increase endothelial NO production, and are therefore critical for men with ED who are under age 60 years, and/or have diabetes, hypertension or coronary artery disease, who are at increased risk of serious or even fatal cardiac events. Phosphodiesterase inhibitors have recently been shown to improve antioxidant status and NO production and allow more frequent and sustained penile exercise. Some angiotensin II receptor blockers decrease oxidative stress and improve vascular and erectile function and are therefore preferred choices for lowering blood pressure in men with ED. Lifestyle modifications, including physical and penile-specific exercise, weight loss, omega-3 and folic acid supplements, reduced intakes of fat and sugar, and improved antioxidant status through diet and/or supplements should be integrated into any comprehensive approach to maximizing erectile function, resulting in greater overall success and patient satisfaction, as well as improved vascular health and longevity.

Managed health care coverage for infertility services: understanding adverse selection.

Insurance is an economic tool that individuals can use to reduce or eliminate financial risk. Health insurance provides risk reduction for economic loss caused by the need to pay for health care services. Insurance for any circumstance makes economic sense provided that administrative expenses to the insurer (insurance company or health plan) are no larger than the risk-premium or the value to the insured of having economic risk reduced or eliminated. Infertility has generally been regarded as a social problem rather than a medical one. Insurance companies and health plans have been reluctant to cover infertility services because of a lack of societal agreement that these services should be included and because accurate information about both the appropriate sequence of care and its cost effectiveness has not been available. Some health plans that have extended coverage for infertility services have experienced poor economic outcomes because of adverse selection. Adverse selection occurs when asymmetrical information exists, i.e. when those insured have privately held information about whether they will need the covered services or not. There are ways that the private sector can reduce or eliminate adverse selection without government mandates. These include limited coverage, experience rating, exclusion for pre-existing conditions, mandatory wait provisions, medical examinations and group coverage. When private sector efforts to control for adverse selection fail, government intervention may make sense. Governmental mandates are favoured by some because they compel wide coverage, which reduces overall economic risk. Even this can fail to eliminate adverse selection if individuals or couples who are higher risk for infertility move to areas where coverage is mandated. Given societal acceptance of the need for universal coverage for infertility services, the private sector should be able to create an economically beneficial insurance market for this coverage provided that they avoid adverse selection.

Hysterectomy: improving the patient's decision-making process.

Increasingly, patients are expecting to be more involved than they traditionally have been in medical and surgical decision making. The unilateral process of informed consent is evolving into one of informed collaborative choice. Hysterectomy is a procedure that is frequently performed when reasonable surgical and nonsurgical alternatives remain. When professional consensus as to the clear recommendation for hysterectomy is not present, patient choice is particularly important. Because more than 80% of health-care decisions, including those in which one of the choices is hysterectomy, are elective, gynecologists and other health care providers increasingly will need to develop more efficient and collaborative methods to integrate patient autonomy and choice into the decision-making process. There is mounting evidence that both clinical and nonclinical outcomes (satisfaction and cost) may be improved when properly informed consumers collaborate in making medical and surgical decisions. Legal liability for adverse outcomes may be decreased by increased patient participation in medical and surgical decision making. The era of managed care has created an agency problem stemming from the fact that consumers (patients) are concerned that necessary procedures and other treatments may be withheld because of cost considerations. Health plans and medical groups likely will be required to provide objective information about the options that consumers (patients) have when faced with choices, including decision making and hysterectomy. By incorporating patient expectations and preferences as part of the process of decision making, an ethically acceptable and effective method of "rationing by patient choice" may be feasible. Figure 3 is a graphic depiction of such a process of informed collaborative choice progressing from effective choices through efficient choices and then to the one providing the best value for an individual patient.

Managed care in benign gynecology.

Although managed care has been viewed by many as an intrusion into medical practice, the stated goals of its proponents are to improve practice outcomes in a cost-effective manner and change the focus of health care to disease prevention and rational clinical resource utilization. Because health care costs have risen consistently in excess of normal inflation, pressure has mounted to move away from traditional fee-for-service reimbursement and indemnity insurance to capitated payment and 'third party' managed care. Studies have shown that the number of providers of gynecologic care is currently in excess of demand based on a managed-care model. Success in managed care will therefore require an understanding of the new economics of health care and a commitment to the appropriate use of medical and surgical interventions. Research should focus on identifying and reducing the unintended and wasteful variation in practice style that currently exists for benign gynecology and all of health care. Clinical guidelines that are derived from actual measured outcomes and adjusted for severity of illness and co-morbid conditions should replace 'clinical opinion' and allow gynecologists to efficiently manage patients with a minimum of third-party interference.

Effect of epidural analgesia for labor on the cesarean delivery rate.

OBJECTIVE: To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. DATA SOURCES: The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. METHODS OF STUDY SELECTION: We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. DATA EXTRACTION AND SYNTHESIS: The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies. CONCLUSIONS: The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.

Making continual improvements to health care.

Health care organizations are looking for new ways to optimize the way that they provide health services. The notion that high quality health care means high costs is no longer accepted without question. Business organizations that found themselves at very high levels of inefficiency, not unlike the levels being seen in hospitals and clinics today, were able to transform their businesses by applying the principles of continual improvement. The components of knowledge for improvement, i.e., knowledge of a system, knowledge of variation, knowledge of psychology, and the theory of knowledge may seem to some too obvious to be recognized and applied on a daily basis in the workplace. Businesses and organizations that are failing, however, often lack this knowledge. We cannot be certain that management by continual improvement can or should be applied or modified to work in all health care organizations. Although the delivery of health care services is a business unlike any other, it has much in common with other service industries. The idea that the quality of patient care can be improved by using the principles of continual improvement currently is being tested.

Office sonography and office hysteroscopy.

Researchers involved in assessing technology and healthcare, including gynecologic care, have identified differences among the terms efficacy, effectiveness and efficiency. In order to assess the efficiency of procedures such as office sonography and hysteroscopy, it is first necessary to compare them with the alternatives in terms of patient-focused outcomes. Office sonography has been used to diagnose early pregnancy disorders such as ectopic gestations and evaluate other adnexal pathology, with mixed results. The use of office hysteroscopy to assess abnormal bleeding may replace procedures that are associated with greater risk and expense. More information regarding outcomes is needed for both procedures before they can be recommended as efficient alternatives for the diagnosis or treatment of gynecologic conditions.

Long-term effects of transdermal estradiol with and without medroxyprogesterone acetate.

OBJECTIVE: To study the long-term biological and metabolical effects of estradiol (E2) administered by transdermal therapeutic systems with and without the addition of medroxyprogesterone acetate (MPA). DESIGN: Open, randomized, comparative trial. SETTING: The reproductive endocrine unit of a tertiary care university-affiliated hospital. PATIENTS: Fifty-seven postmenopausal women were given E2 transdermally, whereas 28 were randomized to take MPA by mouth. Fifteen premenopausal women were studied for comparison. INTERVENTIONS: Estradiol, 0.1 mg, was administered by a transdermal therapeutic system for 24.5 of 28 days and was cycled for 96 weeks. Medroxyprogesterone acetate, 10 mg, was given for days 13 to 25 of each 28-day cycle (E+P group), whereas the remainder received E2 only. MAIN OUTCOME MEASURES: Serum E2, estrone (E1), luteinizing hormone, follicle-stimulating hormone, low-density, high-density, very low-density, and total cholesterol, triglycerides, blood pressure, renin substrate, plasma renin activity, and serum aldosterone levels were measured in all subjects at baseline and in the postmenopausal women every 24 weeks until the end of study. RESULTS: Mean +/- SE levels of E2 rose significantly from baseline at 24 weeks to 426 and 355 pmol/L for the E only and E+P groups, respectively. Smaller increases of estrone (E1) were observed to 263 and 244 pmol/L for the same respective groups. As expected, baseline levels of both gonadotropins were elevated, fell significantly with E2 administration, but remained increased in comparison with values observed in younger women. Decreases of total and low-density lipoprotein (LDL) cholesterol were observed in both groups that reached statistical significance at 48 weeks or later with the exception of LDL cholesterol in the E only group. No significant change of high-density lipoprotein or very low-density lipoprotein cholesterol or triglycerides was observed. There were reductions of mean systolic and diastolic blood pressures in both groups that reached significance at 72 weeks. Mean baseline plasma renin substrate, plasma renin activity, and serum aldosterone levels were within the ranges observed in younger, healthy women and did not change significantly with E2 administration in either group. CONCLUSION: These data support the long-term efficacy and safety of this form of replacement therapy, particularly in combination with MPA, in women with a uterus.

Appropriateness of hysterectomies performed for multiple preoperative indications.

OBJECTIVE: To correlate the listing of multiple preoperative indications for hysterectomy with the risk of non-confirmation of the preoperative diagnosis. METHODS: Records of 171 women undergoing consecutive hysterectomies for all indications at a large teaching hospital were reviewed for preoperative indication(s), compliance with published preoperative validation criteria for cases in which tissue pathology was not expected, and histologic verification of the preoperative diagnosis for cases in which tissue pathology was expected. Rates of confirmation (histologic verification plus successful compliance with validation criteria) of the preoperative diagnosis were compared between subgroups of cases in which single indications were listed (N = 124) or multiple indications were listed (N = 47) preoperatively. RESULTS: The rate of confirmation of single indications (115 of 124 cases, 93%) was significantly higher than the rate of confirmation of even one indication in cases in which multiple indications were listed (28 of 47 cases, 60%, P < .0001; relative risk for non-confirmation of multiple indications = 1.55). Multiple indications were more likely to be listed when tissue pathology was not expected, representing 49% of validatable indications as compared with only 18% of histologically verifiable indications (P < .0001). Overall, the rate of compliance with validation criteria (70%) was significantly lower than the rate of histologic verification (90%) (P < .01). CONCLUSION: These data suggest that listing of multiple preoperative indications for hysterectomy is associated with both decreased appropriateness, as reflected in decreased compliance with generally accepted preoperative validation criteria, and decreased diagnostic accuracy, as reflected in lower rates of histologic verification.

Identification of motile sperm in caput epididymis. Intraoperative observations and clinical correlations.

This retrospective review of patients who underwent vasoepididymostomy demonstrates that motile sperm may be identified in the most proximal portion of the epididymis, and implies that induction of sperm motility may be independent of transit through the epididymis. Although further studies are needed, the data imply that it may not be necessary to identify motile sperm in the epididymal fluid to achieve a successful vasoepididymostomy.

Ovulation induction in women age 40 and older: the importance of basal follicle-stimulating hormone level and chronological age.

OBJECTIVES: To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induction and to assess the impact of basal follicle-stimulating hormone (FSH) on outcome in these patients. DESIGN: Prospective, observational. SETTING: Fertility service of university medical center. PATIENTS: Infertile couples in whom the female partner was age 40 or older referred for ovulation induction therapy. INTERVENTION: Assessment of basal hormonal status; ovulation induction. MAIN OUTCOME MEASURES: Clinical pregnancy rate (PR), livebirth rate. RESULTS: Analysis of 402 cycles in 85 women age 40 and older demonstrated a clinical PR of 3.5% per cycle (95% confidence interval [CI] 1.7% to 5.3%). The livebirth rate was 1.2% per cycle (95% CI 0.1% to 2.3%). Women with a basal FSH < 25 IU/L and age < 44 years had a clinical PR of 5.2% per cycle (95% CI 2.5% to 7.9%) compared with 0.0% per cycle (95% CI 0.0% to 2.1%) in cases in which either basal FSH was > or = 25 IU/L or age was > or = 44 (P < 0.005). The prognostic importance of basal FSH and chronological age was confirmed by multivariate logistic regression analysis. The predictive value of the resulting regression equation was high (R2 = 0.94; P < 0.01). CONCLUSIONS: Pregnancy and livebirth rates are generally low during ovulation induction in women age 40 and older. In combination, basal FSH and chronological age are accurate predictors of PR, in these couples and can define a subset of patients with a more favorable prognosis. The spontaneous abortion rate in women who do conceive is high, substantially lowering the livebirth rate.

Routine hysterectomy for large asymptomatic uterine leiomyomata: a reappraisal.

As part of an ongoing quality improvement process, the records of 104 consecutive patients undergoing hysterectomy for uterine leiomyomata were reviewed. The diagnosis was confirmed histologically in 93 cases (89%) and in eight of the remaining 11, other disease such as adenomyosis or an ovarian neoplasm was discovered. The 93 consecutive patients with a confirmed diagnosis of uterine leiomyomata were then stratified according to preoperative estimate of uterine size and actual uterine weight. The physician's clinical estimate of uterine size correlated well with specimen weight (r = 0.65, P less than .001). Intraoperative estimated blood loss correlated less well with actual change in hematocrit (r = 0.31, P = .03). Women with a uterine size estimate larger than 12 weeks' gestation were no more likely to suffer perioperative complications than were those with smaller uteri. Furthermore, there was no significant increase in mean estimated blood loss or blood transfusion in women with larger uteri compared with those with smaller uteri. We conclude that there is no increase in adverse short-term outcomes associated with hysterectomy for leiomyomata in women with uteri greater than 12 weeks' size. Therefore, hysterectomy need not be routinely recommended to asymptomatic women with larger uteri as prophylaxis against increased operative morbidity associated with future growth.

Rate-based calculation of failure to progress: a proposed quality improvement method.

The rate of "failure to progress" as the indication for primary cesarean delivery used by the Joint Commission on Accreditation of Health Care Organizations is based upon the total number of cesareans performed for this indication divided by the total number of primary cesareans. This denominator includes a large number of patients who are not at risk for the diagnosis of failure to progress, including cases of malpresentation or multiple gestation in which cesarean is performed without trial of labor. Each of these variables may vary dramatically between individual physicians and institutions. Inclusion of patients not at risk for failure to progress results in a misclassification bias, which renders this rate less meaningful for purposes of comparison and trend assessment. We describe a simple method that bases the rate of failure to progress upon the population at risk for this diagnosis; that is, the total number of vaginal deliveries plus primary cesareans for failure to progress minus vaginal births after cesarean. Such a method controls for multiple differences in local practice standards and allows more meaningful assessment of trends and intra-institutional and inter-regional comparisons.

Long-term transdermal estradiol therapy: effects on endometrial histology and bleeding patterns.

Sixty postmenopausal women were enrolled in a 2-year randomized unmasked trial to determine the long-term safety of estradiol (E2) administration by a transdermal therapeutic system. Group I subjects received 0.1 mg of transdermal E2 for 24.5 days of each 28-day cycle for 96 weeks. Group II subjects received the same dosage of transdermal E2 plus 10 mg of medroxyprogesterone acetate, given orally from days 13-25 of each cycle. Vaginal bleeding patterns and endometrial histology were characterized. The subjects recorded bleeding patterns daily. Endometrial biopsies were performed during scheduled follow-up visits at 48 and 96 weeks or as needed to evaluate abnormal bleeding. Data were analyzed by intention to treat. Ten and four subjects dropped out of the study from groups I and II, respectively. A total of 575 and 627 treatment cycles were observed in the same respective groups. Vaginal bleeding was observed in 980 cycles: 381 of 575 cycles in group I (66.3%) and 599 of 627 cycles in group II (95.5%). Bleeding onset, duration, and quantity were similar for both groups. The incidence of hyperplasia was 42 and 4% for groups I and II, respectively, over the 96-week study period. All cases of hyperplasia in group I were treated with sequential medroxyprogesterone acetate for 12 weeks, followed by rebiopsy. In ten of 11 cases, the progestin therapy converted the hyperplasia to a normal endometrium. In one case, the endometrium became hyperplastic again at 96 weeks, but reverted to normal with 12 weeks of medroxyprogesterone acetate.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain.

After a comprehensive clinical and psychological evaluation, 99 women with pelvic pain of at least 6 months' duration and normal findings at laparoscopy were divided into two groups, including 47 women with probable somatic causes of pain (group 1) and 52 women without identifiable somatic abnormality (group 2). Women without identifiable somatic abnormality (group 2) were younger, had higher mean somatization scores, and reported an earlier mean age at first intercourse, a higher number of total sexual partners, and a higher prevalence of sexual abuse before the age of 20. Within group 2 (nonsomatic pain) but not within group 1, mean somatization scores were significantly higher among women with a history of sexual abuse than among women with a negative history. When analyzed as risks for nonsomatic pelvic pain, the positive predictive value of both a history of sexual abuse and a high somatization score was 78% (relative risk compared with that of women with zero or one risk factor, 2.1; p less than 0.0001). These data suggest that the psychosocial profile of women with nonsomatic pelvic pain differs from that of women with somatic pelvic pain and that previous sexual abuse is a significant predisposing risk for somatization and non-somatic chronic pelvic pain.