Obstetrics and gynaecology Archives - Page 11 of 11

Obstetrics and gynaecology

Clinical Articles

What Now with Vaginal Mesh for Prolapse?

Based on an interview with Melbourne urologist, Dr Caroline Dowling conducted in March, 2018 Australia was the first country to ban vaginal mesh products used surgically via transvaginal implantation for the treatment of pelvic organ prolapse. Australia was also a leader in evaluating the complications of these implant, through large scale research.¹ On November 28^th 2017, the Therapeutic Goods Administration withdrew implants for use in prolapse, stating it “was of the belief that the benefits of using transvaginal mesh products in the treatment of pelvic organ prolapse do not outweigh the risks these products pose to patients”. There are unique risks related to mesh use. These include mesh erosion (up to 14% of cases)¹, vaginal and groin pain (up to 3% to 4%)¹ and mesh exposure. These complications may be more common and more severe (requiring surgery) if the mesh is used for prolapse repair, as opposed to the treatment of stress incontinence. Reports of complications associated with transvaginal mesh products began over a decade, with the Food and Drug Administration issuing an alert about their use back in 2008. Repeated warnings were then given. In 2013, legal action began in Australia with 300 women registering for a national class action against Johnson & Johnson Medical Australia. So what do GPs tell their patients who have a vaginal mesh in situ, and what alternative managements are there for vaginal prolapse and stress incontinence? Patients who feel they have complications should be reviewed by the surgeon who operated on them, but it worth noting that most women have had no problems with these products and so, in the absence of symptoms may be reassured that they need no further management. “Women who have no problems from their transvaginal mesh implants should be reassured that they do not require them to be removed,” says Melbourne urologist Dr Caroline Dowling There is not an inherent risk with mesh as an implant, it is used widely in general surgery for inguinal hernia and abdominal wound repair. Nonetheless, it would be wise to explain the possible side-effects of the vaginal mesh in case these occur in the future. Alternatives to the vaginal mesh implant are the traditional vaginal prolapse repair using native tissue, and these are effective procedures for most women seeking surgical treatment of their prolapse. There are several alternatives to mesh for the treatment of stress incontinence that has failed conservative therapy, including an autologous fascial sling, bulking agents and Burch colposuspension. In 2015, the Cochrane Incontinence Group concluded that mid-urethral slings were highly effective in the short-term and medium-term and had a good safety profile. The mid-urethral sling remains available in its retropubic and transobturator form, but patients can no longer access mini-slings or single incision slings outside trial settings. This may change once the results of longer term studies become available. Single incisions may have a more favourable side-effect profile than full-length slings. More conservative management includes pelvic floor exercises and silicon pessaries inserted for prolapse and stress incontinence treatment. Pelvic floor exercises may be difficult to do effectively and repeatedly for many women, especially over time. They may also be less effective in cases of significant cystocoele. Silicon pessaries are particularly useful in women who are symptomatic but wish to have further pregnancies, in women who do not want surgery, in the elderly and for those in poor health.³Patients may need help with the insertion and correct placement, but pessaries work well and may be an underutilised option.

A/Prof. Christopher Maher, Explaining the Vaginal Mesh Controversy. Royal Brisbane and Women's and Wesley Hospitals Brisbane, The University of Queensland. June 17^th

https://medicine.uq.edu.au/article/2017/06/explaining-vaginal-mesh-controversy

Ford et al. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Incontinence Group, July 2015.

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD006375.pub3/abstract

Jones, K. Harmanli, O. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320

Expert/s: Dr Vivienne Miller

Obstetrics and gynaecology

Clinical Articles

Cheapest Option Just as Good for Vaginal Atrophy

Post-menopausal women experiencing vulvovaginal symptoms will benefit just as much from using the cheapest over-the-counter lubricant or moisturiser as using topical oestrogen, a new study suggests. The 12-week randomised clinical trial, published in JAMA Internal Medicine, compared the efficacy of a low-dose vaginal oestradiol tablet and a vaginal moisturiser, each versus placebo among a group of over 300 post-menopausal women with moderate to severe vulvovaginal symptoms. To determine the effectiveness of the treatment women were asked to report on the severity of their ‘most bothersome symptom’ which included pain with vaginal penetration (60%), dryness (21%), itching (7%), irritation (6%) and pain (5%). Across the board, regardless of which treatment was used, most women had a decrease of at least 50% in symptom severity over the course of the study. This was significant in light of the fact that most women said they ‘frequently’ or ‘always’ distressed about their sex life at enrolment, whereas after the 12-week study nearly half said they were ‘rarely’ or ‘never’ distressed. “No treatment group differences in symptom reduction were observed for vaginal oestradiol tablet plus placebo gel vs dual placebo, or vaginal moisturiser plus placebo tablet vs dual placebo”, the US researchers reported. And it didn’t matter if the most bothersome symptom was dyspareunia or itching, it appeared the hormone treatment or the specific vaginal moisturiser (Replens) had no advantage over the placebo combination. According to the study authors, the placebo gel used in the study had a similar pH and viscosity as the vaginal moisturiser (Replens) but was less mucoadhesive. The fact that both formulations were equally effective in reducing symptoms suggests that the mucoadhesive properties are less important than previously thought. Similarly, markers of vaginal oestrogenisation such as the vaginal maturation index, did, naturally improve more with the topical oestrogen but this did not translate into a greater benefit in terms of symptoms over placebo. As an accompanying editorial points out, “ultimately, it is improvement in symptoms rather than surrogates such as tissue markers that should define the goal of care.” And while the study authors conclude that treatment choice for women with troublesome postmenopausal vulvovaginal symptoms should be ‘based on individual patient preferences regarding cost and formulation’ the editorial authors go in much stronger. “[P]ostmenopausal women experiencing vulvovaginal symptoms should choose the cheapest moisturiser or lubricant available over the counter – at least until new evidence arises to suggest there is any benefit to doing otherwise.” Ref: JAMA Intern Med. doi:10.1001/jamainternmed.2018.0116 JAMA Intern Med. doi:10.1001/jamainternmed.2018.0094

Expert/s: Dr Linda Calabresi

Obstetrics and gynaecology

Clinical Articles

Fatter mothers behind rise in perinatal complications

The increasing BMI of first-time pregnant women is behind a rise in adverse perinatal outcomes over a 25 year time period, a new retrospective Australian study suggests. Analysing data from one major Sydney teaching hospital, researchers found that the prevalence of overweight among women having their first baby increased from 12.7% in 1990-94 to 16.4% in 2010-14, and that of obesity rose from 4.8% to 7.3%. More importantly they found this increase in BMI was associated with a range of adverse perinatal outcomes particularly pre-eclampsia, macrosomia and gestational diabetes. Other complications believed to have increased as a result of the maternal weight gain included caesarean deliveries, post partum haemorrhage, prematurity, admission to the special care nursery and fetal abnormalities. “We found that a substantial proportion of the burden of adverse perinatal outcomes for Australian women is linked to maternal overweight and obesity, and that this proportion has steadily increased over the past 25 years,” the Sydney researchers said. The study involved the analysis of the data recorded on over 42000 singleton births delivered to previously nulliparous women at the Royal Prince Alfred Hospital Sydney between 1990 and 2014. Interestingly over the course of the study period, the mean age for first time mothers rose from 28.7 to 31.6 years, however having adjusted for this as well as other possible confounders such as changing smoking rates, socioeconomic status, and country of birth of the mother the findings confirmed the relative risks of adverse perinatal outcomes had increased in association with rising prevalence of overweight and obesity. Researchers calculated that should overweight or obese women move down one BMI category (for example from obese to overweight) 19% of pre-eclampsia, 15.9% of macrosomia and 14.2% of gestational diabetes could be averted. “Our results indicate that the frequency of adverse perinatal outcomes could be reduced by shifting the distribution of overweight and obesity among first-time mothers by a single BMI class. Investing in obesity prevention strategies that target women prior to their becoming pregnant is likely to provide the greatest benefit,” they concluded. Ref: MJA doi:10.5694/mja17.00344

Expert/s: Dr Linda Calabresi

Obstetrics and gynaecology

Clinical Articles

Pregnancy doesn’t ‘cure’ endometriosis, so where does this advice come from?

Many Australian women with endometriosis are reporting they’re being advised a reliable treatment or even possible cure for their endometriosis is to “go away and have a baby”. This message is consistent with what women from other countries are also being told by a wide range of sources from self-help books to web forums to medical professionals. Pregnancy as a natural cure for endometriosis appears to date back to the early 20th century. However, even into the 1950s and 1960s, when pregnancy was commonly recommended as a treatment for endometriosis, this evidence was based mostly on case reports of women whose endometriosis improved during pregnancy. Case reports are often unusual findings and don’t necessarily reflect what happens to most people. Pregnancy as a treatment for endometriosis does not appear in current international guidelines for the management of endometriosis. It’s also not mentioned as a treatment by Australian pelvic pain specialists and is classed as a “myth” by reputable endometriosis support sites.
Read more: Women with endometriosis need support, not judgement

Endometriosis and the lack of a cure

Endometriosis is the presence of tissue similar to the lining of the uterus outside the uterus itself. Accurate estimates of how many women in Australia have endometriosis are hard to find, but a common figure is around one in ten women during their reproductive years. While severe pain during the period is a common symptom of endometriosis, it’s so much more than just a “really bad period”. There’s almost no area of women’s lives that is not negatively affected by the condition. Current medical treatments, often using hormone therapy, are not always effective. And the side effects of many of the hormonal treatments can be particularly unpleasant for women, leading them to stop treatment. Excision surgery, in which the endometrial lesions are cut away, is the most effective current treatment. But surgery is not something most women enter into lightly, given the cost and risk of undergoing surgery. Unfortunately, even surgery is not always successful with around 50% of women having symptoms reoccur after five years. When we look at women around the world, it looks like having children does decrease the amount of period pain women have. A significant problem with this is we don’t know if these women had endometriosis, and these kinds of studies can’t tell us for sure if getting pregnant was responsible for this reduction in period pain.

Read more: Women aren’t responsible for endometriosis, nor should they be expected to cure themselves

Pregnancy, pain and the brain

Women with endometriosis, like other chronic pain conditions, have changes in the way their brains process pain. Nerves, especially in the pelvis, are also more sensitive than in women without chronic pain. The concept of “calming” these hyperactive pain pathways is an important treatment strategy in treating chronic endometriosis pain. Each time menstruation occurs it irritates these sensitive nerves and reinforces these pain pathways. One way to prevent this reinforcement of pain pathways can be by stopping regular menstruation entirely. This is a key reason women with endometriosis are so often treated with continuous use of hormonal contraceptives. During pregnancy there’s also a suppression of menstruation. So it’s possible during pregnancy there will be a reduction in endometriosis-related pain. It’s also just as possible pregnancy will make endometriosis-related pain worse, due to extra pressure on these sensitive pelvic nerves. We just don’t have the research to be able to answer this.

Read more - Health Check: are painful periods normal?

After giving birth, it’s quite possible the pain, if it had decreased, will return. This is especially true once women start having regular periods again, as there’s no evidence pregnancy shrinks endometrial lesions or changes pain processing in the long term, both major drivers of endometriosis pain.

Should pregnancy be recommended as a treatment?

Pregnancy might help reduce endometriosis symptoms, if only temporarily. But women with endometriosis often rightly feel upset and offended when advised to have a baby as a treatment strategy. There are also risks involved, as women with endometriosis are more likely to have pre-term births, increased rates of caesarean sections and an increased risk of miscarriage. Women shouldn’t have to bring another human into the world to relieve the pain of endometriosis. This is why we need to prioritise understanding the cause of endometriosis, finding effective treatments and eventually a cure.

Syl Freedman, Co-founder EndoActive, M.A. Health Communication, MPhil (Medicine) Candidate, University of Sydney contributed to this article. Mike Armour, Post-doctoral research fellow in women's health,NICM, Western Sydney University This article was originally published on The Conversation. Read the original article.

Expert/s: Dr Mike Armour

Obstetrics and gynaecology

Clinical Articles

Could It Be Endometriosis?

Endometriosis, or more particularly diagnosis of endometriosis is often a challenge in general practice. When should you start investigating a young girl with painful periods? Is it worth investigating or should we just put them on the Pill? At what point should these young women be referred? Consequently, the most recent NICE guidelines on the diagnosis and management of endometriosis, published in the BMJ will be of interest to any GP who manages young women. According to the UK guidelines, there is commonly a delay of up to 10 years between the development of symptoms and the diagnosis of endometriosis, despite the condition affecting an estimated 10% of women in the reproductive age group. Endometriosis should be suspected in women who have one or more of the following symptoms:

chronic pelvic pain

period pain that is severe enough to affect their activities

deep pain associated with or just after sex

period-related bowel symptoms such as painful bowel movements

period-related urinary symptoms such as dysuria or even haematuria

Sometimes it can be worthwhile to get the patient to keep a symptom diary especially if they are unsure if their symptoms are indeed cyclical. Women who present with infertility and a history of one or more of these symptoms should also be suspected as having endometriosis.

Investigations

With regard investigations, the guidelines importantly state that endometriosis cannot be ruled out by a normal examination and pelvic ultrasound. Nonetheless after abdominal and pelvic examination, transvaginal ultrasound should be the first investigation to identify endometriomas and deep endometriosis that has affected other organs such as the bowel or bladder. Transabdominal ultrasounds are a worthwhile alternative in women for whom a transvaginal ultrasound is not appropriate. MRI might be appropriate as a second line investigation but only to determine the extent of the disease. It should not be used for initial diagnosis. Similarly, the serum CA-125 is an inappropriate and unreliable diagnostic test. Diagnostic laparoscopy is reserved for women with suspected endometriosis who have a normal ultrasound.

Treatment

If the symptoms of endometriosis can’t be adequately controlled with analgesia, the guidelines recommend hormonal treatment with either the combined oral contraceptive pill or progestogen. Women need to be aware that this will reduce pain and will have no permanent negative effect on fertility. Surgical options to treat endometriosis need to be considered in women whose symptoms remain intolerable despite hormonal treatment, if the endometriosis is extensive involving other organs or if fertility is a priority and it is suspected that the endometriosis might be affecting the woman’s ability to fall pregnant. All in all, these guidelines from the Royal College of Obstetricians and Gynaecologists don’t offer much in the way of new treatments but they do provide a framework to help GPs manage suspected cases of endometriosis and hopefully reduce that time delay between symptom-onset and diagnosis. BMJ 2017; 358: j3935 doi: 10.1136/bmj.j3935

Expert/s: Dr Linda Calabresi