Treatment of patients with Mayer-Rokitansky- Küster-Hauser syndrome in a tertiary hospital.

INTRODUCTION: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an uncommon congenital malformation characterised by agenesis or hypoplasia of the vagina and uterus. Here, we describe the treatment of patients with MRKH syndrome in a tertiary hospital. METHODS: This retrospective study included patients with MRKH syndrome attending the Paediatric and Adolescent Gynaecology Clinic in a tertiary hospital. Their clinical manifestations, examinations, and methods for neovagina creation were recorded. Among patients who underwent vaginal dilation (VD), therapy duration, vaginal width and length at baseline and after VD, complications, and sexual activity and dyspareunia outcomes were evaluated. RESULTS: Forty nine patients with MRKH syndrome were identified. Their mean age at presentation was 17.9 years; 69.4% and 24.5% of patients presented for primary amenorrhoea treatment and vaginoplasty, respectively. Forty eight patients had normal renal imaging findings and 46 XX karyotypes. Seventeen (34.7%) patients underwent VD as first-line therapy; three did not complete the therapy. Two had surgical vaginoplasty, whereas five achieved adequate vaginal length by sexual intercourse alone; 25 had not yet requested VD. The mean duration of VD was 16±10.2 (range, 4-35) weeks. The widths and lengths of the vagina at baseline and after VD were 1.1±0.28 cm and 1.3±0.7 cm, and 3.1±0.5 cm and 6.9±0.9 cm, respectively. The overall success rate of VD was 92.3%. Vaginal spotting was the most common complication (21%); only one patient reported dyspareunia. CONCLUSIONS: Mayer-Rokitansky-Küster-Hauser syndrome is an uncommon condition that requires multidisciplinary specialist care. Vaginal dilation is an effective first-line approach for neovagina creation.

Mothers' attitude to the use of a combined oral contraceptive pill by their daughters for menstrual disorders or contraception.

INTRODUCTION: Mothers' attitude may affect use of combined oral contraceptive pills by their daughters. We explored Chinese mothers' knowledge of and attitudes towards the use of combined oral contraceptive pills by their daughters for menstrual disorders or contraception, and evaluate the factors affecting their attitude. METHODS: This survey was conducted from October 2012 to March 2013, and recruited Chinese women who attended a gynaecology clinic or accompanied their daughter to a gynaecology clinic, and who had one or more daughters aged 10 to 18 years. They completed a 41-item questionnaire to assess their knowledge of and attitude towards use of the combined oral contraceptive pills by their daughters. The demographic data of the mothers and their personal experience in using the pills were also collected. RESULTS: A total of 300 women with a mean age of 45.2 (standard deviation, 5.0) years completed the questionnaire. Only 58.3% of women reported that they had knowledge about the combined oral contraceptive pills; among them, a majority (63.3%) reported that their source of knowledge came from medical professionals. Of a total possible score of 22, their mean knowledge score for risk, side-effects, benefits, and contra-indications to use of combined oral contraceptive pills was only 5.0 (standard deviation, 4.7). If the medical recommendation to use an oral contraceptive was to manage their daughter's dysmenorrhoea, menorrhagia, acne, or contraception needs, 32.0%, 39.3%, 21.0% and 29.7%, respectively would accept this advice. Women who were an ever-user of combined oral contraceptive pills or who were more knowledgeable about combined oral contraceptives had a higher acceptance rate. CONCLUSIONS: Chinese women had a low acceptance level of using combined oral contraceptive pills as a legitimate treatment for their daughters. This was associated with lack of knowledge or a high degree of uncertainty about their risks and benefits. It is important that health caregivers provide up-to-date information about combined oral contraceptive pills to women and their daughters.

Antenatal pelvic floor biometry is related to levator ani muscle injury.

OBJECTIVE: To evaluate the relationship between antenatal pelvic floor biometry and levator ani muscle (LAM) injury in Chinese women. METHODS: Three-dimensional transperineal ultrasound was performed in nulliparous Chinese women with a singleton pregnancy at 9-12 weeks, 26-28 weeks and 36-38 weeks of gestation and again at 12 months after delivery. Hiatal anteroposterior (AP) diameter, transverse diameter and area were measured on the antenatal ultrasound volumes obtained at rest, on Valsalva maneuver and during pelvic floor muscle contraction (PFMC). LAM injury was evaluated using ultrasound volumes obtained during PFMC at 12 months after delivery. RESULTS: In total, 328 women completed the study. At 12 months after delivery, 38 (14.8% of those who delivered vaginally) women had LAM injury; 28 were unilateral (14 right- and 14 left-sided) and 10 were bilateral. In all three trimesters there was smaller hiatal AP diameter and hiatal area in women with LAM injury when compared with women without injury. On multivariable analysis of the three factors, hiatal AP diameter at rest, hiatal area at rest and operative vaginal delivery, only hiatal AP diameter at rest in all three trimesters was an independent factor of LAM injury. A larger hiatal AP diameter at rest in the first, second and third trimesters reduced the likelihood of LAM injury with odds ratios of 0.21, 0.15 and 0.21, respectively. CONCLUSIONS: A smaller antenatal hiatal AP diameter at rest is a risk factor for LAM injury. The hiatal AP diameter is relatively simple to measure and the error in measurement is relatively small. A prospective study to confirm this relationship and to explore whether this measurement, performed in the midsagittal plane, is repeatable should be performed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Effect of levator ani muscle injury on primiparous women during the first year after childbirth.

INTRODUCTION AND HYPOTHESIS: To evaluate the effect of levator ani muscle (LAM) injury on pelvic floor disorders and health-related quality of life in Chinese primiparous women during the first year after delivery. METHODS: At 8 weeks and 12 months after delivery, 328 women were assessed for symptoms of pelvic floor disorders and quality of life using the standardised questionnaire, POP-Q; and translabial ultrasound to detect LAM injury. Descriptive analysis, independent sample t test, non-parametric testing, Chi-squared test and two-sided Fisher's exact test were used. RESULTS: At 8 weeks after delivery, 48 (19.0% [95% CI, 14.2-23.8%]) women with vaginal delivery had LAM injury; 38 women (79.2%) had persistent LAM injury at 12 months. At 8 weeks, LAM injury was associated with prolapse symptoms, descent at Pelvic Organ Prolapse Quantification (POP-Q) Aa and Ba points and a higher Pelvic Organ Prolapse Distress Inventory (POPDI) general and Urinary Distress Inventory (UDI) Obstructive subscale score. At 12 months, it was not associated with prolapse symptoms, Pelvic Floor Distress Inventory (PFDI) or Pelvic Floor Impact Questionnaire (PFIQ). There was also no association between stress urinary incontinence (SUI), urge urinary incontinence (UUI), mixed urinary incontinence (UI), faecal incontinence (FI) with LAM injury at both time points. CONCLUSIONS: Seventy-nine per cent of women who had LAM injury at 8 weeks after vaginal delivery had persistent LAM injury at 12 months. LAM injury was associated with prolapse symptoms, lower POP-Q Aa and Ba points at 8 weeks after delivery and a higher POPDI general and UDI Obstructive subscale scoring. However, we are not able to confirm the association between LAM injury and SUI, UUI, mixed UI, FI at 8 weeks or 12 months after delivery; or prolapse symptoms, PFDI or PFIQ scores at 12 months after delivery.

Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study.

OBJECTIVE: To assess pelvic floor biometry during pregnancy and the correlation with symptoms of pelvic floor disorders in women. DESIGN: A prospective observational study. SETTING: Antenatal clinic between August 2009 and May 2011. POPULATION: Nulliparous women in their first pregnancy. METHODS: Pelvic floor was assessed by translabial ultrasound and symptoms of pelvic floor disorders were explored with a standardised questionnaire at each trimester. MAIN OUTCOME MEASURES: Pelvic floor biometry during pregnancy. RESULTS: A total of 405 (91.6%) women completed the study. As the pregnancy advanced, there was significant descent of the bladder neck (BN), cervix, and anorectal junction. The hiatal area (HA) was significantly enlarged, with a mean increase of 15.1 ± 24.8% at rest, and 24.7 ± 28.5% at Valsalva, at third trimester when compared with first trimester. Risk factors for stress urinary incontinence (SUI) were: descent of BN at Valsalva (OR 3.2, 95% CI 1.2-8.5), increase in HA at pelvic floor contraction (PFMC; OR 1.3, 95% CI 1.0-1.6), and increase in maternal age (OR 1.1, 95% CI 1.0-1.2), at first trimester; increase in HA at PFMC (OR 1.3, 95% CI 1.1-1.5) at second trimester; and descent of BN at rest (OR 2.3, 95% CI 1.1-4.9) and increase in maternal age (OR 1.1, 95% CI 1.02-1.2) at third trimester. Descent of anorectal junction (OR 1.5, 95% CI 1.1-1.9) and increase in HA at rest (OR 1.2, 95% CI 1.0-1.3) were factors for prolapse symptoms at second and third trimester, respectively. CONCLUSIONS: Pelvic floor changes begin during pregnancy. There was significant descent of the BN, cervix, and anorectal junction, and enlargement of the hiatal area, as the pregnancy advanced. SUI was associated with descent of the BN, and prolapse symptoms were associated with an increase in the hiatal area.

Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study.

OBJECTIVES: To evaluate pelvic floor biometry in Chinese women 1 year following childbirth and to explore factors that affect it. METHODS: Translabial ultrasound examination was performed at rest, on Valsalva maneuver (VM) and on pelvic floor muscle contraction (PFMC) in the first, second and third trimesters of pregnancy and at 8 weeks, 6 months and 12 months after delivery in a cohort of women delivering at term their first child. Offline analysis was undertaken to measure the position of the bladder neck, cervix, anorectal junction and hiatal dimensions at each posture and at each visit, and to detect levator ani muscle (LAM) injury on PFMC 8 weeks and 12 months after delivery. Results were analyzed according to mode of delivery. RESULTS: We recruited 442 women, of whom 328 (74.2%) completed the study; there was LAM injury in 48 women at 8 weeks and in only 38 women at 12 months. When comparing first-trimester biometry to that at 12 months after delivery, the bladder neck was more distal on VM and bladder neck displacement was increased, and the cervix was lower at rest and on VM in the vaginal delivery group. In the Cesarean section group, bladder neck and anorectal junction were more distal on VM, the cervix was lower at rest, on VM and on PFMC, and the hiatal area was increased on VM. There was a greater increase in hiatal area after vaginal delivery. Overall, 34.8% had irreversible hiatal distension (> 20% increase in hiatal area after delivery as compared to first trimester). LAM injury was significantly associated with irreversible hiatal distension (odds ratios, 5.2-9.5 at different postures). CONCLUSIONS: Pregnancy beyond 35 weeks of gestation has an effect on the pelvic floor of Chinese women, irrespective of mode of delivery. The pelvic organs remain more mobile after delivery when compared to in the first trimester, and there is no clear difference between the findings observed following vaginal delivery or Cesarean section, except in hiatal distension, which is greater after vaginal delivery. LAM injury is the factor most strongly associated with irreversible hiatal distension.

Prevalence of urinary and fecal incontinence in Chinese women during and after their first pregnancy.

INTRODUCTION AND HYPOTHESIS: This study evaluated factors and their prevalence associated with urinary (UI) and fecal (FI) incontinence during and after a woman's first pregnancy. METHODS: Nulliparous Chinese women with no UI or FI before pregnancy were studied with a standardized questionnaire for UI and FI from early pregnancy until 12 months after childbirth. Maternal characteristics and obstetric data were analyzed using descriptive analysis, independent sample t test, chi-square test, and logistic regression. RESULTS: Three hundred and twenty-eight (74.2 %) women completed the study. The prevalence of antenatal UI increased with gestation. Overall, 192 (58.5 %), 60 (18.3 %), and 76 (23.1 %) had normal vaginal delivery, instrumental delivery, and cesarean section, respectively. Twelve months after delivery, prevalence of stress urinary incontinence (SUI) and urge urinary incontinence (UUI) was 25.9 % [95 % confidence interval (CI) 21.5-30.6] and 8.2 % (95 % CI 5.2-11.2), respectively. In those who delivered vaginally, the prevalence was 29.7 % and 9.1 %, respectively. Prevalence of FI was 4.0 % (95 % CI 1.9-6.1). On logistic regression, vaginal delivery [odds ratio (OR) 3.6], antenatal SUI (OR 2.8), and UUI (OR 2.4) were associated with SUI. Antenatal UUI (OR 6.4) and increasing maternal body mass index (BMI) at the first trimester (OR 1.2) were associated with UUI. Antenatal FI was associated with FI (OR 6.1). CONCLUSIONS: The prevalence of SUI, UUI, and FI were 25.9 %, 8.2 %, and 4.0 %, respectively, 12 months after delivery. Vaginal delivery, antenatal SUI, and UUI were associated with SUI; antenatal UUI and increasing maternal BMI at the first trimester were associated with UUI. Antenatal FI was associated with FI. Pregnancy, regardless of route of delivery and obstetric practice, had an effect on UI and FI.

Menstrual disorders in a Paediatric and Adolescent Gynaecology Clinic: patient presentations and longitudinal outcomes.

OBJECTIVE. To study the presentations, diagnoses, and outcomes in adolescents with menstrual disorders. DESIGN. Prospective cohort study. SETTING. Paediatric and Adolescent Gynaecology Clinic, Hong Kong. PARTICIPANTS. A total of 577 adolescents aged 14 to 19 years. MAIN OUTCOME MEASURES. The presentations and diagnoses of adolescents with menstrual disorders were reviewed and their menstrual outcomes determined by a telephone survey. RESULTS. In all, 47% presented with menorrhagia, prolonged menstruation, and short menstrual cycles; 27% had secondary amenorrhoea, 12% had dysmenorrhoea, 11% had oligomenorrhoea, and 3% had primary amenorrhoea. Significant diagnoses included congenital genital tract anomalies, premature ovarian failure, anorexia nervosa, and polycystic ovarian syndrome. Polycystic ovarian syndrome was diagnosed in 16% of the cohort. In all, 24% of these 577 patients had abnormal menstrual cycles 4 years later. Direct logistic regression analysis indicated a cycle length of more than 35 days at presentation (adjusted odds ratio=2.8; 95% confidence interval, 1.8-4.5), previous diagnosis of polycystic ovarian syndrome (adjusted odds ratio=2.0; 95% confidence interval, 1.1-3.4), and current body mass index of 23 kg/m(2) or higher (adjusted odds ratio=1.8; 95% confidence interval, 1.0-3.0) were risk factors for persistently long menstrual cycle exceeding 35 days. Adolescents who were screened out with a definitive diagnosis after initial assessment were at low risk of persistently long menstrual cycles at follow-up (adjusted odds ratio=0.3; 95% confidence interval, 0.1-0.8). CONCLUSIONS. Adolescent menstrual disorders should not be ignored. Long cycle, diagnosis of polycystic ovarian syndrome at first consultation, and a current body mass index of 23 kg/m(2) or higher were statistically associated with persistent problems.

Menstrual problems and health-seeking behaviour in Hong Kong Chinese girls.

OBJECTIVE: To ascertain the prevalence of menstrual problems in adolescent girls and their health-seeking behaviour. DESIGN: Questionnaire survey on menstruation, menstrual problems, medical consultation, and factors influencing girls seeking medical care. SETTING: Secondary schools in the catchment area of a tertiary teaching hospital in Hong Kong. PARTICIPANTS: A total of 5609 girls from 10 secondary schools. MAIN OUTCOME MEASURES: Prevalence of menstrual problems and health-seeking behaviour of adolescent girls. RESULTS: The mean age of the girls and their mean age at menarche were 15.1 (standard deviation, 2.0) years and 12.3 (1.1) years, respectively. The prevalence of menorrhagia, dysmenorrhoea, and menstrual symptoms were 17.9% (95% confidence interval, 16.9-19.1%), 68.7% (67.7-70.3%), and 37.7% (36.7-39.3%), respectively. The prevalence of menstrual symptoms (P<0.001) and dysmenorrhoea (P<0.001) increased with gynaecological age (calendar age minus age at menarche), whilst the proportion having short or long cycles decreased (P=0.002 and P=0.009). One in eight girls reported having been absent from school, whilst only 6.4% had sought medical care because of menses. Multivariate analysis indicated that seeking medical care for menorrhagia was dependent on the opinion of a family member (P=0.005), and for dysmenorrhoea on its severity (P=0.046) and anxiety about embarrassing questions (P=0.039). CONCLUSIONS: The prevalence of menstrual problems in Hong Kong Chinese girls is high and causes significant disruption to their school and daily activities. However, only a minority seek medical advice.