Uterine artery embolization, hysterectomy, or myomectomy for symptomatic uterine fibroids: a cost-utility analysis.

OBJECTIVE: To compare the cost and quality-adjusted life-years (QALYs) of hysterectomy, myomectomy, and uterine artery embolization (UAE) for symptomatic control of uterine fibroids. DESIGN: A cost-utility analysis conducted by using Markov modeling. SETTING: The analysis was conducted from the perspective of Hong Kong society. PATIENT(S): A hypothetical cohort of patients presenting with symptomatic uterine fibroids. INTERVENTION(S): Hysterectomy, myomectomy, or UAE. MAIN OUTCOME MEASURE(S): Health-care resource use and QALYs over 5 years. RESULT(S): The base-case analysis showed that hysterectomy was the most effective treatment (4.368 QALYs), followed by myomectomy (4.273 QALYs) and UAE (4.245 QALYs) over 5 years. Hysterectomy was less costly (USD8418) (1USD = 7.8HKD) than UAE (USD8847) and myomectomy (USD9036). Monte Carlo 10,000 simulations showed that the hysterectomy group was less costly than the UAE and myomectomy groups 84.1% and 79.1% of the time, and it also gained higher number of QALYs than the UAE and myomectomy groups over 97% of the time. CONCLUSION(S): Hysterectomy appears to be more cost-effective than myomectomy and UAE for management of symptomatic uterine fibroids over a 5-year period among patients who do not have a preference for uterus-conserving interventions.

Preferred frequency of menstruation in Hong Kong Chinese women: characteristics and factors.

Although menstrual extended regimens have been available in the market, limited study has been conducted on preferred menstrual characteristics in Asian women. This study aimed to investigate Chinese women's preferences on menstrual characteristics and factors affecting their preferences. Cross-sectional telephone survey of 1024 Hong Kong Chinese women in 2006. A total of 67.8% of women preferred one or more changes in menstrual characteristics and 35.9% preferred no menstruation. Although 57.7% of women knew that hormones can control and/or suppress menstruation, only 14.4% would consider using hormones to attain their ideal menstrual characteristics. Reduction in society activities (OR = 1.83, 95% CI 1.30, 2.57) and reduction in sleeping quality (OR = 1.54, 95% CI 1.12, 2.12) were significant predicators of preference for less menstruation. Hong Kong Chinese women are interested in changing their menstrual patterns but only a small portion would like to use hormones to attain their ideal menstrual characteristics.

Comparison of the different types of "laparoscopic total hysterectomy".

STUDY OBJECTIVE: To review the operative outcomes among different types of laparoscopic total hysterectomy (LH) classified according to the Munro and Parker classification system. DESIGN: Prospective observational cohort study (Canadian Task Force classification II). SETTING: 6 major public hospitals in Hong Kong. PATIENTS: 143 patients underwent LH in a 6-month period. INTERVENTIONS: Type I to type IV LH according to the Munro and Parker classification system. MEASUREMENTS AND MAIN RESULTS: We studied 56 type I, 49 type II, 25 type III, and 13 type IV LH. The median operative time was 105 minutes, which was significantly longer in the type IV LH group (160 minutes). The median blood loss was significantly higher in the type I LH group (300 mL). The incidence of urinary tract infection in type I LH was 8.9%, which was significantly higher than other LH groups. The overall operative complication rate was 20.3%, which was highest in the type III hysterectomy group (36%), although the difference did not reach statistical significance among the various types of hysterectomy groups. CONCLUSION: There has been a change from abdominal hysterectomy to LH in the past decades, and it is time for us to explore the best type of LH. Our findings suggest that type I LH is associated with significantly more blood loss and urinary tract infection; whereas type IV LH is associated with significantly longer operating time. However, we still cannot conclude which is the best type of LH until results from a randomized controlled trial will become available.

The additive interactions between ondansetron and droperidol for preventing postoperative nausea and vomiting.

Prophylactic ondansetron or droperidol reduces the incidence of postoperative nausea and vomiting (PONV). Previous studies showed that the combination of these two drugs produced better antiemetic effect than either drug alone. We present a nonparametric method to determine the pharmacologic interaction between ondansetron and droperidol and compared the observed response of the drug combination with that predicted from additivity. This is calculated as the product of the individual drug response, normalized to that of the controls. Five minutes before induction of anesthesia, 400 patients scheduled for laparoscopic gynecologic surgery were randomly assigned to receive 1) saline IV; 2) ondansetron 4 mg IV; 3) droperidol 1.25 mg IV; or 4) a combination of droperiodol 1.25 mg and ondansetron 4 mg IV. A standardized anesthetic technique and postoperative analgesic regimen were used. Patients were reviewed regularly for 48 h. Changes in the heart rate adjusted QT (QTc) interval were measured from electrocardiograms recorded before and 5 min after study drug administration. In a subgroup of 160 patients, QTc intervals were measured again at 2-3 h after surgery. During the first 48 h after the surgery, the proportion of patients experiencing PONV was 68% (95% CI 58-77) in the control group. A single dose of ondansetron or droperidol decreased the incidence of PONV to 30% (95% CI 21-40) and 28% (95% CI 20-38), respectively. The predicted incidence of PONV after drug combination, 11.8% (7.1-11.9), was similar to that observed, 12.1% (6.4-20.2), P = 0.94. The corresponding predicted and observed treatment responses in the combination group were 88.2% and 87.9%, respectively. There was a modest and transient increase in QTc interval after administration of ondansetron, droperidol, or their combination. The changes were however similar among groups. We conclude that the interaction between ondansetron and droperiodol was additive. Both drugs acted independently of each other through their specific mechanisms of action. The incidence of QTc prolongation did not increase with the drug combination.

Health status function after treatment with thermal balloon endometrial ablation and levonorgestrel intrauterine system for idiopathic menorrhagia: a randomized study.

AIM: To compare patients' health status function after treatment with thermal balloon endometrial ablation (TBEA) and levonorgestrel intrauterine system (LNG-IUS) for idiopathic menorrhagia. METHODS: Forty-four patients were recruited into a randomized trial comparing their health status after treatment with TBEA or LNG-IUS for idiopathic menorrhagia. RESULTS: At 1 year follow-up, the mean haemoglobin was significantly higher in women treated with TBEA (12.6 g/dl vs. 10.3 g/dl, p = 0.018). Iron deficiency occurred in 13.3% from the TBEA arm and in 50% from the LNG-IUS arm (p = 0.026). The women's mean Short Form 36 Questionnaire general health perception scores (54.9 vs. 40.5, p = 0.024) and mental health scores (49.5 vs. 38.3, p = 0.021) in TBEA arm were significantly higher than in the LNG-IUS arm. The mental health domain score was also significantly lower in the LNG-IUS arm (46.1 vs. 38.3, p = 0.041). CONCLUSION: TBEA appears to offer better health status function at 1 year follow-up and to be more acceptable to our Chinese population in the treatment of idiopathic menorrhagia following failed medical treatment.

Ovarian fibroma: a review on the clinical characteristics, diagnostic difficulties, and management options of 23 cases.

AIM: We review clinical characteristics, diagnostic difficulties, and our experience in the surgical management of ovarian fibromas. METHOD: Twenty-three women with the operative diagnosis of an ovarian fibroma managed between January 1995 and August 2004 were reviewed retrospectively. RESULTS: These patients comprised 1% of all benign ovarian tumors seen over this study period. The median age was 45 years, and 11 patients (47.8%) were postmenopausal. The main presenting symptom was abdominal pain (43.5%). The diagnosis of an ovarian fibroma or a solid ovarian tumor was correctly made preoperatively in only 5 patients (21.7%). All patients underwent surgical treatment: 18 by laparotomy and 5 by laparoscopy. All tumors were unilateral, and the median size was 13 cm. Fourteen patients underwent conservative surgery, and 9 had total abdominal hysterectomy with bilateral salpingo-oophorectomy. Two cases of fibrosarcoma were reviewed on the final pathology. CONCLUSIONS: Gynecologists should be aware of this group of ovarian tumors despite their uncommon occurrence. There are clinical clues to differentiate an ovarian fibroma from uterine fibroid and ovarian malignancy. Surgical removal of these solid ovarian tumors is recommended because of the low probability of malignancy. Minimal-access surgery is an option, especially when the tumor is of moderate or small size.

Sleep disturbances in Chinese pregnant women.

In a prospective study of 247 pregnant Chinese women, the prevalence of sleep disturbances across pregnancy has been assessed using a set of validated questionnaires including the Sleep and Health Questionnaire (SHQ) and the Epworth Sleepiness Scale (ESS). The frequency of self-reported snoring increased from 29.7% in the first trimester to 40.5% and 46.2% in the second and third trimesters, respectively, with an increase in the prevalence of moderate or severe snoring from 1% in the first trimester to 7.2% in the third trimester (P < 0.01). There was a higher frequency of moderate to severe snoring intensity among subjects with BMI >or=25 compared with those with BMI <25 kg/m(2) in the third trimester (20.8%vs 5.3%, P < 0.01). Subjective sleepiness, as determined by the ESS, increased significantly from 8.6 to 9.4 and 9.6 in the first, second and third trimesters, respectively.

Sexual behavior and activity in Chinese pregnant women.

OBJECTIVE: To evaluate sexual activities, attitudes, and complications related to intercourse among Chinese pregnant women and to study their source of the information. METHODS: This was a prospective cross-sectional study. Two hundred and ninety-eight Chinese pregnant women were recruited. Pregnant women completed a self-administered questionnaire anonymously. Their sexual experience and sexuality were analyzed and compared among trimesters. Multiple logistic regression was used to assess the association of various factors with a number of outcomes concerning the sexuality in pregnancy. RESULTS: Ninety-three percent of the pregnant women reported an overall reduction in their sexual activities during pregnancy. Among these activities, vaginal intercourse significantly decreased in the third trimester. Besides gestation, advanced maternal age and nulliparity were independent factors associated with the reduction of vaginal intercourse (P < 0.001). Moreover, over 60% of the women, as well as more than 40% of their partners, had reduction in sexual desire and enjoyment during pregnancy. Over 80% of the women and their partners worried about the adverse effects of sexual activity on the fetus. However, less than 12% of them experienced complications after coitus during pregnancy. Among them, only 9.4% discussed sexuality with their doctors and half of them raised up this topic by themselves. CONCLUSION: Chinese pregnant women had less sexual activities and desire during pregnancy. Culture, inadequate knowledge, and excessive anxiety are likely the important factors for the marked reduction in sexuality in Chinese couples. Medical staffs should take a proactive role in providing more information to relieve their anxiety.

Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage.

BACKGROUND: When compared with the conventional surgical evacuation for the treatment of miscarriage, medical evacuation has been largely accepted as an effective and safe management. However, there is a lack of data on the long-term reproductive outcome of these two treatment modalities, which is crucial in patient counselling. The current study evaluates and compares the long-term fertility and pregnancy outcome following these two treatments. METHODS: A cohort of 604 women enrolled in a previous randomized controlled trial comparing medical and surgical evacuation for miscarriage were followed up prospectively by telephone interview at a median of 6 (range 4-9) years using a structured questionnaire. RESULTS: A total of 423 women were contacted and four declined to participate (response rate 69.4%). Of these, 261 women (131 medical and 130 surgical evacuations) had attempted to become pregnant since the miscarriage. There were no differences in their baseline characteristics including age, reproductive and contraceptive history. The natural conception rates were the same (97.7%, P = 0.99) and the cumulative pregnancy rates were similar between groups, being 60 and 80% at 12 and 24 months respectively. The median time-to-pregnancy was 8 months in both groups (P = 0.97) and the subsequent live birth rates (85.2 versus 88.2%, P = 0.72) resulting from the immediate pregnancy following previous treatment were similar. CONCLUSIONS: The long-term conception rate and pregnancy outcome are not different following medical or surgical evacuation for miscarriage. Women should be reassured that their long-term fertility potential will not be compromised after medical treatment.

Preference on the treatments for menorrhagia in Hong Kong chinese women.

BACKGROUND: Menorrhagia is a common gynecological problem and its management options vary from medical to surgical treatment. With the development of the new minimally invasive therapies, there is a paucity of data in the preference and acceptance on these treatment options, especially in the Chinese population. METHODS: An anonymous survey using a self-constructed questionnaire was undertaken on women with heavy menstrual bleeding referred to the specialty clinic in a university teaching hospital. The aim was to elicit women's knowledge and preferences for the treatment options for menorrhagia. RESULTS: A total of 200 Chinese women returned their questionnaire with a response rate of 62%. Over 90% of them were unaware of other alternative treatment options for menorrhagia. Eumenorrhea was the desired treatment outcome in 173 (86.5%) women while only 15 (7.5%) and 12 (6%) wished to have oligomenorrhea and amenorrhea respectively. Drug therapy was the preferred first-line treatment in 87% and none preferred to undergo hysterectomy. When the medical treatment failed, 16% of women would not accept any other forms of treatment. For the rest of them, an L-norgestrel-releasing intrauterine device was the preferred option in 53.6%, endometrial ablation in 19%, while only 5.4% would prefer hysterectomy. CONCLUSION: The awareness of alternative treatment options for menorrhagia in Hong Kong Chinese women is very deficient and eumenorrhea is the desired treatment outcome, rather than oligomenorrhea or amenorrhea.

Influence of the Women's Health Initiative trial on the practice of prophylactic oophorectomy and the prescription of estrogen therapy.

Physicians have become more conservative regarding prophylactic oophorectomy after publication of the Women's Health Initiative trial. They are less likely to prescribe estrogen therapy for women who have a high risk of coronary heart disease and more likely to use nonoral routes for estrogen therapy.

Life-table analysis of the success of thermal balloon endometrial ablation in the treatment of menorrhagia.

OBJECTIVE: To evaluate the change in intrauterine pressure during thermal balloon endometrial ablation and to identify risk factors associated with treatment failure. DESIGN: Prospective observational study. SETTING: University-affiliated teaching hospital. PATIENT(S): Seventy two consecutive patients with idiopathic menorrhagia refractory to medical treatment. INTERVENTION(S): Thermal balloon endometrial ablation under patient-controlled sedation. MAIN OUTCOME MEASURE(S): Change in intrauterine pressure during the treatment cycle and risk factors associated with treatment failure. RESULT(S): A spontaneous decrease in intrauterine pressure occurred in most patients (93%). The mean (+/-SD) decrease was 34.1 +/- 14.9 mm Hg, or 19.5% +/- 9.1%. The treatment failed in 10 patients (13.9%), and the mean end pressure was significantly lower in this group (131.1 +/- 14.1 mm Hg vs. 145.1 +/- 18.0 mm Hg; P=.02). The chance of success of treatment was significantly lower when the end pressure was <140 mm Hg (odds ratio, 0.42 [95% CI, 0.27 to 0.68]; P=.01), the intrauterine volume was >10 mL (odds ratio, 0.43 [95% CI, 0.22 to 0.83]; P=.058) and the uterus was retroverted (odds ratio, 0.36 [95% CI, 0.20 to 0.65]; P=.008). CONCLUSION(S): Maintaining high intrauterine pressure during the treatment cycle and correction of the retroversion may help to improve treatment success in thermal balloon endometrial ablation.

Successful treatment of ruptured interstitial pregnancy with laparoscopic surgery. A report of 2 cases.

BACKGROUND: Laparoscopic surgery is generally considered contraindicated in women with ruptured interstitial pregnancy as it is associated with profound bleeding and hypovolemic shock. CASES: Two cases of ruptured interstitial pregnancy were treated with laparoscopic surgery. Laparoscopic cornuostomy and removal of products of conception were performed in 1 case and laparoscopic cornual resection in the other. Laparoscopic tubal occlusion performed 4 and 6 months later showed the cornu region to be well healed in both cases. CONCLUSION: With increasing experience with the laparoscopic technique, ruptured interstitial pregnancy can be managed safely and successfully with laparoscopic surgery.

Pitfalls in diagnosis of interstitial pregnancy.

BACKGROUND: To determine the incidence and reasons for misdiagnosis in interstitial ectopic pregnancy. METHODS: We conducted a retrospective study from 1990 to 2001. Women with interstitial pregnancy were identified and their case records retrieved and reviewed. Reasons for delay in diagnosis and associated morbidity were recorded. RESULTS: Thirty-six women were diagnosed as having interstitial pregnancy during the study period. Initial diagnosis was incorrect in 15 cases (41.7%). In 14 cases, the interstitial pregnancies were mistaken as intrauterine pregnancy. These misdiagnoses resulted in six inappropriate surgical procedures (evacuation of uterus) being performed and led to rupture of interstitial pregnancy in eight women. In two women, the interstitial pregnancy was mistaken as normal intrauterine pregnancy while the uterus itself was thought to be a cervical fibroid. In both cases, the interstitial pregnancies ruptured at 18-20 weeks of gestation. CONCLUSION: Despite advances in sonographic skills and equipment and the availability of beta-human chorionic gonadotropin (hCG) monitoring, misdiagnosis of interstitial pregnancy still occurs frequently. Clinicians should be aware of the limitations of various investigations and maintain a high index of suspicion.