Comparison of ovarian electrocautery and oral contraceptives in the treatment of hyperandrogenism in women with polycystic ovary syndrome.

BACKGROUND: Endocrine treatment of hyperandrogenism in women with polycystic ovary syndrome (PCOS) aims at reduction of androgens and increasing sex hormone binding globuline (SHBG), which are also side effects of ovarian electrocautery (OE) when used for induction of ovulation. METHODS: Hormonal effects of ovarian electrocautery were compared with the effects of oral contraceptives (OC) containing desogestrel (DG) or cyproteron acetate (CPA). OCs were given to 18 women with PCOS as their sole treatment (group A) and to 23 women after the restoration of regular ovulatory cycling by ovarian electrocautery (group B). RESULTS: Ovarian electrocautery induced ovulation and increased the concentration of estrogens and especially progesterone, while OC induced the opposite effects. In the androgens and SHBG the two treatments induced changes that were in the same direction, but OC treatment induced changes that exceeded those of OE. The concentration of SHBG increased from 27.9 to 127.7 nmol/L on OC treatment (Group A), compared with 37.2 to 44.9 after OE (Group B). The androgens decreased, for testosterone the decreases were 2.1 and 0.99 nmol/L, respectively, for androsterone 5.36 and 3 nmol/L, for dihydrotestosterone 0.12 and 0.1 nmol/L, and for DHEAS 3.28 and 1.8 umol/L. No further gain was obtained by the combination of the two treatments. CONCLUSIONS: Hyperandrogenism in women with PCOS can be effectively treated with OCs containing DG or CPA. In women with concurrent infertility, however, ovarian electrocautery can be recommended. The only indication for the combination of these two treatments is ambivalence with regard to the fertility after ovulation induction by OE. A temporary delay of ovulatory cycling with OC-treatment after OE has no negative impact upon the future fertility.

Contact activation factors in plasma from women on estrogen replacement therapy after ovariohysterectomy.

The plasma levels of factor XII, prekallikrein, factor XI, and high molecular weight kininogen were studied in women with bilateral oophorectomy and hysterectomy who received hormone replacement therapy with a 2 mg daily dose of estradiol valerate. Also plasminogen activator activity was investigated. The observations made provide support for the assumption that the low doses of estrogen used in hormone replacement therapy do not significantly affect the levels of contact activation or fibrinolytic factors in plasma. Plasma obtained from young, healthy women was used as a standard reference material. Significantly higher levels of factor XII and prekallikrein were registered in functional tests in the ectomized women than in the reference material, an increase not observed in the immunological assays. These observations are discussed in light of recently published data from our laboratory on an increase in the measured level of factor XII obtained upon the removal of IgG before assay. Also a marked increase in urokinase activity was registered in the ectomized women. The high levels of factor XII, prekallikrein, and urokinase, as compared with the reference material, seemed to be age dependent, being also observed in a group of naturally postmenopausal women.

Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome.

OBJECTIVE: To examine the duration of the changes in endocrine indices produced by ovarian electrocautery in women with polycystic ovary syndrome (PCOS). DESIGN: Long-term observational study. SETTING: University hospital. PATIENT(S): Infertile women with PCOS. INTERVENTION(S): Ovarian electrocautery was performed through the laparoscope. Blood was sampled before the operation and at defined intervals thereafter. After the establishment of regular cycles, sampling was performed 1 week before the menstrual period. MAIN OUTCOME MEASURE(S): The patients were observed before and at defined intervals for up to 20 years after ovarian electrocautery. Serum concentrations of hypophyseal and ovarian hormones were determined, including sex hormone-binding globulin (SHBG). RESULT(S): There was a clear shift from anovulation to ovulatory cycles and a significant decrease in androgens and gonadotropins. The concentration of SHBG increased. These effects lasted for many years; after 18-20 years, two thirds of the women were still ovulating. CONCLUSION(S): Ovarian electrocautery for PCOS normalizes ovarian function, including androgen production, and the results seem to be stable for 18-20 years.

Treatment in polycystic ovarian syndrome (PCOS) with emphasis on ovarian electrocautery.

The current opinion about the diagnosis and treatment of polycystic ovarian syndrome is presented. The advantages of ovarian electrocautery, the method pioneered by the author of the paper, is emphasised. Endocrine short and long term effects and the effectiveness of ovarian electrocautery in the infertility treatment are reviewed.

Ovarian electrocautery in the treatment of women with polycystic ovary syndrome (PCOS). Factors affecting the results.

During the years 1979-91 252 women with polycystic ovarian syndrome (PCOS) have been treated with ovarian electrocautery through the laparoscope in Aker University Hospital. Ovulation was obtained in 92% of the total series, and pregnancy in 84% of the women with PCOS as the sole cause of their infertility. Additional treatment with clomiphene citrate to the non-responders increased the pregnancy rate to 89%. The response to ovarian electrocautery was influenced by body weight, with an ovulation rae of 96-97% in the slim and moderately obese women decreasing to 70% in the really obese ones. When ovulation was established, the pregnancy rate per se was independent of body weight-when ovulation was established, the pregnancy rates of slim and overweight women with PCOS being 92% and 95%, respectively. In the responders (who ovulated following ovarian electrocautery), the annual rate of cessation of ovulation was 3-4% only. Even after a period of contraceptive use following the ovarian electrocautery, ovulation was resumed and pregnancy obtained within a few months. Therefore, ovarian electrocautery is proposed as the primary treatment in women with PCOS undergoing laparoscopy for any reason, infertility being a present, future or hypothetical problem only. When, on the other hand, infertility is not an issue, PCOS per se constitutes no reason to perform laparoscopy.

Antimicrobial prophylaxis in gynaecological and obstetric surgery.

Gynaecologic and obstetric surgery generally is prone to infections caused by bacteria from vagina. The vaginal flora contains normally more than 40 different microorganisms. Some of them are obligate pathogens, such as Chlamydia trachomatis, Neisseria gonorrhoeae and serogroup B streptococci, for other microbial species, like mycoplasmas and staphylococci, the pathogenicity is uncertain. The vaginal flora is under the influence of a great number of variables, such as endocrine factors, life style, contraception, and the use of tampons/pads. The recent literature on antibiotic prophylaxis in gynaecology and obstetrics is surveyed. The conclusions are: Antibiotic prophylaxis is recommended in: Abdominal hysterectomy (in high risk cases), in vaginal hysterectomy, fertility surgery, elective abortion and miscarriage (in carriers of C. trachomatis or N. gonorrhoeae), in cerclage (in endocervical colonization), Caesarean section (in high risk cases), and premature rupture of membranes. Great importance is attached to the prevention of infection of the neonates, with emphasis on the transmission of serogroup B streptococci and herpes simplex virus. The prevention of postoperative and postpartum urinary tract infections is discussed.

A simple treatment for polycystic ovarian syndrome.

Good results are reported from Norway in the treatment of polycystic ovarian syndrome by laparoscopic electrocautery of the ovary. The method may prove particularly valuable in parts of the world where drugs are difficult to obtain and where social or geographical circumstances impede follow-up.

The course and outcome of pregnancy after ovarian electrocautery in women with polycystic ovarian syndrome: the influence of body-weight.

In 89 women with polycystic ovary syndrome (PCOS) who conceived after ovarian electrocautery, the pregnancy continued beyond 31 weeks in 62. In this group the frequency of pre-eclampsia and diabetes was 12.9 and 8.1% respectively. The increased frequencies were confined to overweight women. The frequency of major and minor malformations was 1% and 3.8% respectively. The rate of early miscarriage of the first pregnancy after ovarian electrocautery was 15%, and when later pregnancies were included the rate reduced to 10.3%. These data do not indicate any impact upon the course or outcome of pregnancy from the state of PCOS per se or the ovarian electrocautery that induced ovulation in this series.

Endocrine effects of ovarian electrocautery in patients with polycystic ovarian disease.

The mechanism by which ovarian electrocautery induces regular ovulatory cycles was studied in 16 women with polycystic ovarian disease (PCO) and compared with 25 normal fertile women who were undergoing sterilization by tubal electrocautery. Gonadotrophins (LH and FSH), prolactin, androgens, oestrogens, 17-hydroxyprogesterone and progesterone were determined immediately before operation and 24 h later. Following the sampling of blood for these tests, 100 micrograms of gonadotrophin releasing hormone (GnRH) was given intravenously and the LH and FSH responses were measured at 30 min. In the PCO-group, these tests were repeated after the first induced ovulatory cycle. After operation, LH increased only in the patients with PCO and this increase was associated with an enhanced response to GnRH, FSH showed a similar response to GnRH, also confined to the PCO-group. These pituitary responses are best explained by a change in ovarian feedback induced by the direct electrocautery of the glands in the PCO-group. There was little change in serum oestrogen. Prolactin showed an increment in all cases and serum androgens were reduced in all groups, most pronounced in the PCO patients, possibly as a result of the stress of operation. An ovarian factor--released or reduced by the electrocautery--seems to be responsible for the changes.

Hormonal response to electrocautery of the ovary in patients with polycystic ovarian disease.

Fifty-eight women with polycystic ovarian syndrome (PCO) were treated with electrocautery of the ovarian capsule and then studied by hormone analysis for 12 months. In 72% ovulation appeared to occur within 4 weeks and in this group mean serum LH and FSH levels showed a statistically significant increase the day after electrocautery, followed by a gradual decline in LH to a level significantly below the pretreatment value. No changes in LH and FSH were seen in those who did not ovulate. The mean levels of testosterone, androstenedione and dihydrotestosterone which were in the upper normal range or slightly above before treatment were significantly reduced after electrocautery. Serum oestradiol levels showed a significant increase after 1 week, when progesterone levels were still unchanged, suggesting that follicular development was already in progress. The mean serum level of sex hormone binding globulin was slightly below the normal range before treatment and then increased gradually. Endocrine responses to electrocautery were similar to those described previously after wedge resection. The simplicity of this treatment and the good response make it an attractive alternative for treating infertility associated with PCO.

Metronidazole in the treatment of non-specific vaginitis (NSV).

In a large multicentre study of 429 patients with the usual signs and symptoms of non-specific vaginitis (NSV), we studied the effect of different doses of metronidazole. The patients were divided into five treatment groups as follows: group A was given 400 mg metronidazole three times daily for seven days, group B 2000 mg as a single dose, group C 2000 mg on days 1 and 2, group D 2000 mg on days 1 and 3, and group E was given 1200 mg metronidazole once daily for five days. At follow up examination four weeks from the start of treatment, patients in groups D and E showed the best clinical results with cure rates of 94.0% and 93.6% respectively. In addition the rate of reisolation of Gardnerella vaginalis was lowest in group D. We therefore recommend metronidazole 2000 mg on days 1 and 3 as routine treatment for non-specific or vaginitis associated with gardnerella.

Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope.

Sixty-two women with the polycystic ovarian syndrome were treated by systematic electrocautery of the ovarian capsule performed by laparoscopy. Ovulation occurred within 3 months in 92%. Regular menstrual cycles were established in 51 patients (86%) and plasma progesterone levels suggested that these were ovulatory. Seven of nine women who had been resistant to treatment with clomiphene, 150 mg daily, and human chorionic gonadotropin, 6000 to 9000 IU, ovulated after electrocauterization. The remaining two women responded to stimulation with clomiphene. Pregnancy occurred in 24 of 35 subjects who were involuntarily infertile (69%), with the pregnancy rate increasing to 80% with the inclusion of the women sensitive to clomiphene. These findings support the theory that ovulation is triggered by local factors within the ovary itself.

Pelvic inflammatory disease: etiologic studies with emphasis on chlamydial infection.

Chlamydia trachomatis is one of the main etiologic agents in pelvic inflammatory disease (PID) in Oslo. Up to two thirds of the 65 PID cases studied were associated with a chlamydial infection. The incidence of cervical gonorrhea was low (7.7%). Anaerobic bacteria were not isolated from the fallopian tubes or peritoneal fluid of any of the patients. Chlamydia-associated PID is characterized by a protracted course and vague symptoms. The laparoscopic findings indicate more severe inflammatory changes of the tubes than in patients in whom these agents were not found. The highest incidence of chlamydia-associated PID occurred in younger subjects, among whom the intrauterine contraceptive device was more frequently used. Perihepatitis was diagnosed in PID patients with and without chlamydial infection of the genital tract.

Antibiotic levels in plasma and peritoneal fluid after amoxycillin, ampicillin, and bacampicillin treatment for pelvic inflammatory disease.

Fifteen patients with pelvic inflammatory disease had a thin polyethylene catheter inserted through the abdominal wall into the pouch of Douglas for sampling of peritoneal fluid. At hourly intervals peritoneal fluid and capillary blood were collected. Five patients each received a single oral dose of either 0.5 g of ampicillin or amoxycillin, or 0.8 g of bacampicillin (approximately equimolar doses). This highest median peak plasma level was observed after bacampicillin. Bacampicillin also showed less variation in individual plasma concentration. The area below the plasma curve was similar for amoxycillin and bacampicillin, whereas that of ampicillin was significantly smaller (p less than 0.01). The rate of penetration into peritoneal fluid was slower for amoxycillin than for bacampicillin, even though the area below the peritoneal fluid curve was similar for the two drugs. Therapeutic levels were maintained for 5--8 hours, longer after amoxycillin than after bacampicillin.

Treatment of Chlamydia trachomatis infections of the female lower genital tract.

Chlamydia trachomatis infections of the female lower genital tract may cause cervicitis, a condition which, even when asymptomatic, as it often is, can have serious consequences in both the short and the long term. Treatment, therefore, should be instituted as soon as such infections are diagnosed. Tetracyclines are the therapy of choice, with erythromycin and trimethoprim/sulfamethoxazole as therapeutic alternatives. The duration of treatment should be for not less than 8 to 10 days. Concomitant infections with C. trachomatis and Neisseria gonorrhoeae require special therapeutic considerations. As with any other sexually transmitted infection, management of chlamydial infections demands simultaneous partner treatment. Screening by culture is proposed for high-risk groups, such as women applying for legal abortion and those undergoing implantation of an intrauterine contraceptive device.

Chlamydia trachomatis as a cause of acute perihepatitis associated with pelvic inflammatory disease.

Of four cases of acute salpingitis and perihepatitis confirmed by laparoscopy Chlamydia trachomatis was cultured from the cervix only in two and from both the cervix uteri and the Fallopian tubes in two; the latter finding has not been reported from cases with combined salpingitis and perihepatitis (Fitz-Hugh-Curtis syndrome). Since gonococci, other aerobic, or anaerobic bacteria were not isolated from the Fallopian tubes, an aetiological relationship between C trachomatis and the Fitz-Hugh-Curtis syndrome is suggested.