[Photodynamic diagnosis and therapy in gynecology--current knowledge]

Photodynamic diagnosis (PDD) is a new method based on the detection of different forms of fluorescence of tissues after previous administration of photosensitizers. The photosensitizer is gathered in the pathological tissue at much higher concentration than in the healthy tissue, thus the fluorescence differs. Localizing wrong fluorescence allows precise choosing of the spot to collect tissue for histopathological or cytological study. Photodynamic therapy (PDT) is a technique in which tissue is irradiated with light after the use of a photosensitizing drug that produces singlet oxygen, which has a cytotoxic effect. The authors describe new trends in photodynamic diagnosis and treatment of some vulvar epithelial diseases (VIN, lichen sclerosus, condylomata acuminata) and cervical intraepithelial neoplasia. They describe photodynamic method in their own studies: diagnosis and treatment of lichen sclerosus and diagnosis of uterine cervix cancer.

[Photodynamic diagnosis of vulvar precancerous conditions and invasive cancers using 5-aminolevulinic acid]

BACKGROUND

Photodynamic therapy (PDT), in particular Photodynamic diagnosis (PDD) is a modern, non-invasive technique using photosensitizer like 5-aminolevulinic acid (5-ALA) in detection of the vulvar diseases. Photodynamic therapy gives the possibilities to differentiate inflammatory diseases from precancerous lesions and invasive vulvar cancer.

OBJECTIVE

To assess accuracy of the PDD in detection, localisation and differentiation of precancerous diseases and invasive cancer of the vulva.

MATERIAL AND METHODS

This study included 107 patients with vulvar disorders, 30 patients with VIN I, 31 patients with VIN II, and 46 patients with VIN III and vulvar carcinoma. All women underwent a standard gynaecologic examination. 5-ALA was topically applied to the vulva. After 180-360 minutes the vulvar skin was illuminated by a short--are xenon lamp at 380-440 nm and an output of 200 mW (D-Light; Karl storz). A filter to select the emitted wavelength range 630-670 nm was used in order to achieve differentiation's of the fluorescence--positive and negative areas. After the PDD, biopsies were taken from patients with multifocal VIN lesions. Macroscopic appearance, fluorescence pattern in scale of three degrees (zero, +, ++) and histology of the lesions were compared.

RESULTS

The sensitivity, specificity, positive and negative predictive value for the detection of VIN I were 85.7%, 81.2%, 80.0%, 86.6% respectively, for VIN II there were 93.3%, 93.7%, 93.3% and 93.7%, and for VIN III and invasive vulvar cancer there were 96.3%, 94.7%, 96.3% and 94.7% respectively. The sensitivity, specificity, positive and negative predictive value for the detection of all VIN and invasive vulvar cancer common were 92.9%, 90.2%, 91.2%, 92.0 respectively.

CONCLUSION

The Photodynamic therapy becomes a valuable, non-invasive diagnostic tool that lowers the amount of false negative diagnosis in cases of VIN and vulvar cancer.

Pelvic examination teaching: linking medical student professionalism and clinical competence

The Professional Patient teaching program is an essential part of assuring competency in the performance of the pelvic examination and professional behaviors. Through a series of integrated teaching sessions from the first year reproductive anatomy laboratory, the second year basic clinical pelvic examination teaching program, to the third year teaching program, students perform at an enhanced level of clinical competency and professional behavior. A Professional Patient commented: "We create a safe environment where medical students not only learn the clinical portion of the exam, but also focus on the patient as the primary source of information on patient comfort. Students receive immediate feedback from us and have ample opportunity to ask questions about aspects of the clinical pelvic examination or doctor/patient communication skills. We guide them, teach them, and help them prepare for examinations with other patients who will not be as open or in tune with their bodies as we are."

Advances in the assessment of the uterus and fallopian tube function

Hysterosalpingo-contrast-sonography (HyCoSy) using saline and Echovist is a well tolerated outpatient technique that provides a significant amount of information of relevance to the infertile woman that is not obtainable at hysterosalpingogram (HSG) whilst avoiding exposure to X-ray irradiation. When performed by experienced operators, it serves as a valuable, first-line screening test for the more invasive procedures of laparoscopy and dye chromopertubation and hysteroscopy. If detailed diagnostic information is required in women in whom there is no clinical or ultrasound evidence of pelvic pathology, the surgical technique of fertiloscopy can be considered to be appropriate. This technique permits confirmation that the ovum pick-up mechanism is normal, the tubes are patent and the uterine cavity is normal, while salpingoscopy and microsalpingoscopy permit the assessment of the tubal lumen.

Japanese women's perspectives on pelvic examinations in the United States. Looking behind a cultural curtain

OBJECTIVE

To elucidate overseas Japanese women's preferences on whether to use a curtain to separate themselves from the provider during pelvic examinations in the United States, as practiced in Japan.

STUDY DESIGN

We qualitatively interviewed 19 overseas Japanese women who presented to a clinic serving Japanese people living in southeastern Michigan. We synthesized this interview data into a cohesive overview of the content and used illustrative quotes generated by the participants to provide a context.

RESULTS

Most participants (n = 12) approved of the U.S. style of examination, including the use of private rooms and a sheet to cover the perineum. A minority of women (n = 4) said they were neutral to the approach, 2 preferred the Japanese examination style, and 1 did not like pelvic examinations. Some participants strongly disliked the use of the curtain and the structure of examination rooms in Japan.

CONCLUSION

Most participating women did not support using a curtain during pelvic examinations in the U.S., as practiced in Japan, and some were critical of the Japanese practice. Clinicians may help place their Japanese patients at ease by acknowledging nonuse of a curtain in the U.S., and explaining the intentional use of a private room and sheet to protect patient privacy.

Role of bile acid measurement in pregnancy

The diagnosis of obstetric cholestasis (OC) has serious implications for maternal, and especially fetal, health. Total serum bile acid concentration is an important investigation in any woman with itching in the absence of a rash during pregnancy. Results should be available within 1-2 working days. Pruritus plus raised total bile acids in the third trimester suggests a diagnosis of OC. Other biochemical abnormalities, usually a raised alanine aminotransferase, accompany or follow the finding of raised bile acids. Bile acids are sensitive, but not specific, markers for OC. The diagnosis is one of exclusion. The clinician should remain alert to other causes of liver dysfunction, either specific to pregnancy or not. Effective treatment is available that improves maternal biochemical indices and well-being. It is not clear whether such treatment reduces the risks to the fetus. More active management of OC pregnancies has reduced the associated fetal and perinatal mortality.

In-pouch TV culture system in diagnosis of Trichomonas vaginalis infection

A newly simplified culture method, the In-Pouch TV culture system, the wet mount (WM) examination and the acridine orange stain were compared with the Oxoid culture as a standard technique in the diagnosis of trichomoniasis. Out of 70 symptomatic cases enrolled in this study, 28 specimens were positive by all methods. Among these positive specimens, 21 were positive by the Oxoid culture (75%) and 24 (85.7%) with sensitivity of 85.7% by the In-Pouch system. Both wet mount preparation and acridine orange stain had less sensitivity than the In-Pouch system (61.9%) and detected 15 (53.6%) and 16 (57.1%) of the cases respectively. The In-Pouch system has been proved to be easier in the transport and culture technique than the ordinary culture method. It alleviates the need to enter the culture, thus prevents contamination. Its cost is comparable to the ordinary culture tube. Therefore, it is recommended to use the In-Pouch culture system as a method of diagnosing trichomoniasis.

Pelvic pain and menstrual related illnesses

When approaching the patient with acute pelvic pain, it is imperative to keep in mind the subtle differences each diagnosis can present with. Narrowing down pelvic pain to a specific location in the body while maintaining a high index of suspicion for acute pelvic pain emergencies will aid in a more rapid and accurate diagnosis. Bear in mind that acute pelvic pain is a clinical challenge, and although an exact diagnosis maybe elusive, emergency treatment should always be provided first and foremost despite an exact diagnosis.

Perinatal outcomes in gestational diabetes: a comparison of criteria for diagnosis

OBJECTIVE

The purpose of this study was to compare the perinatal outcomes of women after diagnosis of gestational diabetes by the current American College of Obstetricians and Gynecologists-National Diabetes Data Group recommendations with outcomes after diagnosis by the American Diabetes Association criteria.

STUDY DESIGN

We identified records of 242 women who had had the standard 3-hour oral glucose tolerance test between 1995 and 1999 at the Regional Medical center in Memphis. Patients were categorized into 1 of 3 groups as follows: euglycemic control subjects (n = 69), subjects with gestational diabetes diagnosed by the National Diabetes Data Group criteria (n = 130), and subjects with gestational diabetes diagnosed by the American Diabetes Association criteria (n = 43). Maternal and infant charts were reviewed. Primary outcomes included frequency of cesarean delivery, preeclampsia, and macrosomia. In univariate analysis the chi2 test was used to compare group differences, and in multivariate analysis we used stepwise logistic regression and controlled for confounding factors.

RESULTS

No differences existed among the 3 groups regarding maternal race, body mass index, history of preeclampsia, or family history of diabetes. The frequency of overall cesarean delivery, of cesarean delivery for macrosomia or arrest disorder, of preeclampsia, and of macrosomia did not differ significantly among the 3 groups. Neonatal hypoglycemia was more frequent in the groups with a diagnosis by the American Diabetes Association criteria (23.3%) and by the National Diabetes Data Group criteria (16.2%) than in the control subjects (7.2%), reaching near significance (P =.057). In the multivariate analysis, cesarean delivery for macrosomia or an arrest disorder correlated negatively with parity and positively with body mass index. Preeclampsia was associated with African American race and body mass index; macrosomia correlated with a history of macrosomia and familial diabetes. Neonatal hypoglycemia was more common in the American Diabetes Association group (odds ratio, 2.45; 95% confidence interval, 1.004-5.97) and in the insulin-requiring National Diabetes Data Group category (odds ratio, 3.71; 95% confidence interval, 1.20-11.44).

CONCLUSION

The benefits of defining an additional high-risk population of women with gestational diabetes by the American Diabetes Association criteria are unclear. Further large-scale prospective clinical trials are required.

Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence

OBJECTIVES

To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice.

METHODS

We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997.

RESULTS

Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures.

CONCLUSIONS

We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.

Novel method for intrafollicular pressure measurements in the rat ovary: increased intrafollicular pressure after hCG stimulation

The ovulatory process in the rat comprises a period of about 12-15 h, from the time of the preovulatory LH surge to follicular rupture and extrusion of the oocyte. Follicular rupture is most likely caused, at least in part, by decreased tensile strength at the follicular apex due to degradation of collagen fibres of the extracellular matrix. It has been debated whether changes in intrafollicular pressure occur during the ovulatory process and whether such changes facilitate rupture of the follicle. In the present study, rats were primed with equine chorionic gonadotrophin (eCG, 10 iu) followed by hCG (10 iu) 48 h later. The intrafollicular pressure in the preovulatory follicle was recorded during 1 h at distinct time phases of the ovulatory process by use of an active servo-null pressure system based on the proportionality between electrical resistance and pressure within the tip of an inserted micropipette. The basal intrafollicular pressure was 16.6 +/- 1.0 mm Hg at the preovulatory phase (48 h after eCG) and increased gradually throughout the ovulatory process to 21.4 +/- 2.4 mm Hg at 4-7 h after hCG (mid-ovulatory phase) and 23.9 +/- 1.9 mm Hg at 8-12 h after hCG (late ovulatory phase; significantly higher (P < 0.01) than the preovulatory phase). Short-term peaks of increased pressure, possibly representing contractility, were not detected in follicles of the preovulatory phase, but were seen in most follicles of the mid- and late ovulatory phases. The mean amplitude of the short-term pressure increases was 12.3 +/- 3.2 mm Hg and the increases occurred at intervals of 24.7 +/- 3.6 s. These short-term increments in intrafollicular pressure were still present after hysterectomy had been performed. The wall tension index was calculated by measuring the follicular size and estimating the thickness of the follicle wall. The index increased from 93.9 +/- 13.3 at the preovulatory phase to 207.3 +/- 47.7 (mid-ovulatory phase) and to significantly higher values at the late ovulatory phase (320.9 +/- 33.5). In conclusion, this study shows that there is an increase in intrafollicular pressure in the ovulating follicle of the rat ovary during the late stages of the ovulatory process, and that short-term increases in intrafollicular pressure occur during the late phase of the ovulatory process. These changes in pressure may be essential for follicular rupture to proceed normally.

Preeclamptic pregnancy is associated with increased sympathetic and decreased parasympathetic control of HR

Previous work from our laboratory using heart rate variability (HRV) has demonstrated that women before menopause have a more dominant parasympathetic and less effective sympathetic regulations of heart rate compared with men. Because it is still not clear whether normal or preeclamptic pregnancy coincides with alternations in the autonomic functions, we evaluated the changes of HRV in 17 nonpregnant, 17 normotensive pregnant, and 11 preeclamptic women who were clinically diagnosed without history of diabetic neuropathy, cardiac arrhythmia, and other cardiovascular diseases. Frequency-domain analysis of short-term, stationary R-R intervals was performed to evaluate the total variance, low-frequency power (LF; 0.04-0.15 Hz), high-frequency power (HF; 0.15-0.40 Hz), ratio of LF to HF (LF/HF), and LF in normalized units (LF%). Natural logarithm transformation was applied to variance, LF, HF, and LF/HF for the adjustment of the skewness of distribution. We found that the normal pregnant group had a lower R-R value and HF but had a higher LF/HF and LF% compared with the nonpregnant group. The preeclamptic group had lower HF but higher LF/HF compared with either the normal pregnant or nonpregnant group. Our results suggest that normal pregnancy is associated with a facilitation of sympathetic regulation and an attenuation of parasympathetic influence of heart rate, and such alterations are enhanced in preeclamptic pregnancy.

The significance of an 'insufficient' Pipelle sample in the investigation of post-menopausal bleeding

BACKGROUND

Out-patient endometrial sampling is a commonly performed procedure in the investigation of post-menopausal bleeding. We hypothesized that an 'insufficient' Pipelle sample reliably reflected the absence of serious endometrial pathology.

METHODS AND RESULTS

A review of 141 consecutive cases reported as 'insufficient' for diagnostic purposes revealed 29 (20%) cases to have uterine pathology after secondary investigation. These included two cases of endometrial carcinoma and two other cases of uterine malignancy.

CONCLUSION

These results do not support the initial hypothesis and suggest that in women presenting with post-menopausal bleeding, an 'insufficient' sample is an indication for further investigation.

Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology

We have defined fertiloscopy as the combination in one investigation of transvaginal hydropelviscopy, dye-test, optional salpingoscopy, and hysteroscopy, performed on an outpatient basis under local anaesthesia or neuroleptanalgesia. We have applied this approach in a routine manner to 160 infertile patients with no obvious pathology. Fertiloscopy was achieved in 154 patients (96.2%). In five patients visualization was not satisfactory because of technical problem or adhesions in the pouch of Douglas. We had one (0.6%) rectal injury, which was treated conservatively. Sixty patients (37.5%) had normal fertiloscopic examination. Endometriosis was discovered in 21 patients (13.1%) post-pelvic inflammatory disease (PID) lesions in 58 cases (36.2%), and subtle abnormalities in 15 cases (9.3%). Salpingoscopy was completed when post-PID lesions were encountered. In 39% of cases only partial examination was possible because of external tubal adhesions, but it was nevertheless sufficient to obtain a good view of the first one-third of the ampulla. In all, 74 patients (46.2%) were referred directly to in-vitro fertilization (IVF) procedures, and so avoided a further laparoscopy. Quality of imaging, accuracy of the pelvic examination in a physiological manner, and safety of the procedure are the main advantages of this minimally invasive technique. Selection of the patients for surgery is therefore enhanced, and indication for IVF is better balanced, avoiding the performance of extensive procedures in patients who should thus benefit from this less traumatic alternative.

The management of unexplained infertility

Unexplained infertility is a diagnosis made by exclusion after all of the standard investigations have revealed no abnormality (1). The range of the prevalence is from 6 to 60 percent (23), depending on the diagnostic criteria. This article reviews the literature in the management of unexplained infertility; published data suggest no benefit of danazol or bromocriptine. The empirical use of clomiphene citrate suggests that ovarian stimulation using clomiphene citrate can double the spontaneous pregnancy rate (52, 58, 59). Induction of ovulation with human menopausal gonadotrophin (hMG) yields an overall pregnancy rate between 2 and 26 percent per cycle (68, 74). These results seem to be lower than those reported for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) procedures in similar patients (25-30 percent (92, 95)). Based on the literature, a rational treatment plan for treating infertility in couples with unexplained infertility includes up to four cycles of clomiphene citrate with or without intrauterine insemination (IUI). Superovulation with hMG and IUI or stimulated intrauterine insemination (SIUI) is the next step for three-cycle treatments and if unsuccessful, one of the variants of assisted reproductive techniques (ART) should be considered.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the appropriate tests and work up for unexplained infertility, the various treatment options for the unexplained infertility couple including which drugs are effective and not effective, and to be able to outline an appropriate treatment plan for such patients.