Clinical review

Gynaecology

Con Kelleher, consultant obstetrician and gynaecologist,  Peter Braude, professor of obstetrics and gynaecology. 

Division of Women's and Children's Health, Guy's, King's, and St Thomas's School of Medicine, and Guy's and St Thomas's Hospital Trust, St Thomas's Hospital, London SE1 7EH

Correspondence to: P Braude peter.braude{at}kcl.ac.uk

Improvements in imaging technology, endoscopic equipment, drug treatment, and scientific innovation have all contributed to recent advances in gynaecology. Advances have also resulted from a change in the attitudes and practice of gynaecologists themselves, in response to the greater expectations and knowledge of their patients, who frequently seek new and innovative procedures on the basis of media publicity and access to non-peer reviewed information including the world wide web. It is increasingly recognised that gynaecological problems affect the quality of life of women in different ways, highlighting the value and importance of patient assessed health status measures to evaluate the subjective severity and treatment efficacy of common gynaecological conditions. ^{1 2} Laparoscopic and hysteroscopic surgery, medical treatment, and expectant management are replacing major gynaecological surgery for many common gynaecological complaints. For example, ectopic pregnancy is being diagnosed earlier by the use of transvaginal ultrasonography and quantitative measurements of human chorionic gonadotrophin concentrations. Thus women can be treated either medically as outpatients with methotrexate injections ^{3 4} or by laparoscopic surgery, reducing stay in hospital and preserving tubal function in most cases.^4-6 Minor procedure units for gynaecology, with one stop investigation and treatment (including ultrasonography and hysteroscopy), and early pregnancy assessment units, where bleeding in early pregnancy can be dealt with rapidly and sympathetically, are becoming more commonplace. The prolonged life expectancy of menopausal women and their higher expectations for health have encouraged new developments in hormone replacement therapy. The increased use of such therapy has also increased surveillance and thus recognition of other common problems affecting older women. Delaying childbearing has resulted in a greater demand for effective fertility treatments and for surgical procedures that preserve fertility.

	Methods

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

We asked consultant gynaecological staff at a London teaching hospital for their views on important recent advances in gynaecological practice. Overlap occurred in topics believed to be important, and these are detailed here. To supplement our knowledge of the relevant recent literature, we electronically searched Medline, hand searched the major British and US gynaecological journals published over the past 2 years, and read presentations and abstracts from the 1998 British congress of obstetrics and gynaecology.

	Treatment of menorrhagia

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

Hysterectomy
Heavy menstrual loss is a common complaint and accounts for about 12% of referrals to gynaecology outpatient departments.⁷ Many of these women will undergo hysterectomya woman's lifetime risk of hysterectomy is estimated at 20%. ^{8 9} Despite the success of the procedure compared with other treatments for menorrhagia,¹⁰ the morbidity and complication rates (before and after discharge from hospital) are high.¹¹ The frequency of the operation and its complications have provided incentives to re-evaluate simple medical treatment and to explore new conservative and surgical treatments for dysfunctional uterine bleeding.

Medical treatment
Randomised controlled trials of commonly prescribed medical treatments for menorrhagia have confirmed the efficacy of tranexamic acid¹² and have shown that norethisterone, the most commonly prescribed drug in the United Kingdom for the treatment of ovulatory menorrhagia,¹³ is ineffective at its recommended dosage. ^{14 15} Despite this evidence, a recent survey of 206 general practitioners showed that 69% would still consider prescribing cyclical norethisterone for this condition.¹⁶

Hysteroscopic ablative surgery
If medical treatment fails to treat menorrhagia, an alternative treatment is hysteroscopic ablation of the endometrium. Several techniques are available, and despite initial concerns about safety a recent survey of more than 10 000 operations (MISTLETOE; miminally invasive surgical techniques, laser, endothermal or endoresection) showed that the techniques are safe even in inexperienced hands.¹⁸ At the start of the survey in 1993, 83% of NHS hospitals in the United Kingdom offered ablative surgery. Although randomised trials have shown ablative surgery to be more effective than medical management,¹⁹ the technique is invasive, requires general anaesthesia, is not without complications, and has reduced long term efficacy in women under 45 years of age.²⁰ Recently introduced balloon devices for ablative treatment may prove to be equally efficacious, simpler, and even safer to use than ablative surgery, although further evaluation is awaited.²¹

Intrauterine progestogen releasing system
The levonorgestrel intrauterine system (Mirena; Schering Health Care) may prove to be both an effective contraceptive and a long term treatment for menorrhagia, offering a genuine alternative to surgical intervention for this condition (fig 1). The device can be inserted or removed easily in the outpatient clinic by practitioners with no additional training other than that required for insertion of intrauterine contraceptives, and its effects are completely reversible.²² Recent randomised controlled studies showed that the efficacy of the levonorgestrel intrauterine system is comparable to that of invasive endometrial ablation²³ and that reduction of menstrual loss is significant in most cases.^22-25 Studies have also shown that between 64% and 80% of women awaiting hysterectomy cancel their surgery after a 6 month trial of the device. ^{24 25} The many other potential uses for the device include endometrial protection in hormone replacement therapy, the reduction of climacteric symptoms, and possibly an alternative to sterilisation in women with menorrhagia, although these uses are incompletely evaluated at present. Recent evidence has shown that the levonorgestrel intrauterine system may also reduce the risks of pelvic infection.²⁴

View larger version (33K): [in this window] [in a new window]   Fig 1.   Progestogen releasing intrauterine system (Mirena) releases low dose of progestogen within endometrial cavity (with permission of Schering Health Care)

	Treatment of fibroids

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

The hysteroscopic resection of small submucous fibroids distorting the endometrial cavity is now standard practice (fig 2), but not all fibroids are amenable to this surgical option because of their position and size. In the presence of large symptomatic fibroids, hysterectomy or myomectomy has remained the major treatment option. Recent advances in the long term interventional radiological and medical treatment of large symptomatic myomas offer an important alternative approach.

View larger version (50K): [in this window] [in a new window]   Fig 2.   Submucosal fibroid in endometrial cavity viewed before (above) and during (below) hysteroscopic myomectomy (diathermy resection loop seen)

Bilateral embolisation of uterine arteries
An alternative approach for the treatment of large symptomatic fibroids is bilateral embolisation of the uterine arteries, currently available only at specialist centres as part of an ongoing evaluation process. It has been shown that embolisation of the uterine arteries with polyvinyl alcohol particles introduced transfemorally by catheter can significantly reduce the size of large fibroids (60%-65%) and produce significant symptomatic improvement or complete resolution of symptoms (fig 3).²⁶ The technique is generally well tolerated and requires only a brief admission to hospital for analgesia, although short term side effects such as pyrexia, profuse discharge, and the passage of small or large fibroids through the vagina are common. The treatment is new, and the long term safety and efficacy of fibroid shrinkage are still unknown. Significant morbidity and even mortality as a consequence of infection have resulted from embolisation of the uterine arteries, and it must therefore be considered a new treatment under evaluation until further results are available from large randomised studies. Although pregnancy has been recorded after treatment, ^{27 28} embolisation of the uterine arteries is not recommended for nulliparous women until more data on fertility are available. However, it may be a useful alternative for difficult or dangerous surgery, for those who decline blood transfusion, or for those who refuse surgery.

View larger version (41K): [in this window] [in a new window]   Fig 3.   Catheter course during bilateral embolisation of uterine arteries (normal sized uterus and enlarged uterus with abnormal vasculature)

Gonadotrophin releasing hormone agonists
Although the gonadotrophin releasing hormone agonists are more frequently used in assisted conception, in the management of endometriosis, for the premenstrual syndrome, and to prepare the endometrium before hysteroscopic surgery, they have also been shown to reduce the size of fibroids by up to 50% with short term treatment (3-6 months). This has made them an ideal adjunct to surgery for large symptomatic fibroids.²⁹ The main disadvantages of gonadotrophin releasing hormone agonists are secondary to the induced hypo-oestrogenic state, affecting the cardiovascular, skeletal, and urogenital systems and producing vasomotor symptoms. This has limited their use to short term treatment, the cessation of which leads to a rapid increase of fibroids to their previous dimensions. Thus the short term treatment of fibroids with gonadotrophin releasing hormone agonists alone is a costly and ineffective treatment option.³⁰

Gonadotrophin releasing hormone agonists and "add back" therapy
Add back hormone replacement therapy, the concomitant use of oestrogens, progestogens, or both, aims to counteract the hypo-oestrogenic side effects of gonadotrophin releasing hormone agonists without exacerbating the condition for which they are being used.³¹ This allows the possibility of extended or repeat treatment courses with gonadotrophin releasing hormone agonists for a variety of conditions. Although the best combination has yet to be determined, it would seem that continuous combined oestrogen and progestogen or tibolone (Livial)³² preparations are the most sensible option.

	Overcoming male factor infertility

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

It is now 21 years since the first live birth after fertilisation in vitro to alleviate female tubal infertility. Despite only moderate success (between 9% and 26% live births per cycle started), influenced mainly by maternal age, duration of infertility, and previous parity,³³ in vitro fertilisation is now accepted as an alternative to tubal surgery and for protracted unexplained infertility. In a similar way, the recent ability to achieve fertilisation of eggs in vitro by the injection of a single spermatozoon (intracytoplasmic sperm injection; ICSI)³⁴ has overturned the poor prognosis for men with low sperm counts or azoospermia.³⁵ Adequate spermatozoal samples for intracytoplasmic sperm injection can be obtained from very poor ejaculates, including semen samples frozen for patients undergoing chemotherapy or radiotherapy but too poor to be used for artificial insemination. In men with obstructive azoospermia of infective origin or after failed reversal of vasectomy, sperm for intracytoplasmic sperm injection can be obtained by percutaneous aspiration from the epidydimis (PESA) or from a small testicular biopsy (testicular sperm extraction; TESE), performed under local anaesthesia. This latter technique may be used in men with small testes and a high follicle stimulating hormone concentration who have testicular failure, as multiple small biopsies will show adequate sperm for intracytoplasmic sperm injection in half the cases. Pregnancy success with intracytoplasmic sperm injection is as good as or even better than with in vitro fertilisation, and the outcome seems to be independent of the source of the sperm.³⁵

	Urinary and faecal incontinence

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

The prevalence of urinary incontinence increases with age,³⁶ and important predisposing factors are childbirth and the menopause.³⁷ Recent developments include tolterodine, a specifically targeted antimuscarinic drug (M3 receptors) for treating detrusor instability. Tolterodine reduces non-specific systemic anticholinergic side effects, a major cause of poor compliance with previous drugs.³⁸

Embarrassing conditions, including urinary incontinence, are frequently underreported and consequently unrecognised. Accumulating evidence shows that 1% of women sustain anal sphincter injury during childbirth and that occult sphincter injuryidentified by endoanal sonography³⁹may occur in up to one third of vaginal deliveries.⁴⁰ This results in anal urgency and incontinence in 6%-10% of women post partum, yet less than 20% report their symptoms.⁴¹ Although injury to the anal sphincter cannot be prevented it can be minimised by the use of ventouse in preference to forceps for operative vaginal delivery and by the recognition that liberal use of episiotomy does more harm than good.⁴² In addition, the improved recognition and management of anal sphincter injury at the time of delivery and the use of alternative means of repairing third degree tears, including the overlapping repair, may reduce long term morbidity. Until anal sphincter injury is more fully understood and researched, it is likely that the increase in rate of caesarean sections will continue and that, as recently suggested, it may be difficult to decline a patient's request for caesarean to avoid pelvic floor damage during childbirth on the basis of current evidence.⁴³

	Footnotes

   Competing interests: CK has received reimbursement both from Schering and from Pharmacia and Upjohn for attending symposia.

	References

Top Methods Treatment of menorrhagia Treatment of fibroids Overcoming male factor... Urinary and faecal incontinence References

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(Accepted 10 June 1999)