Management of menopause: a survey of physicians from the Middle East and Africa

OBJECTIVE

This study evaluated physicians' perceptions, practices, confidence, comfort level and prior training in managing menopause.

METHODS

A survey was conducted of a convenience sample of physicians from the Middle East and Africa (MEA) in 2019. We covered knowledge of symptoms, menopausal hormone therapy (MHT), other menopause management strategies and prior training in menopause medicine.

RESULTS

Of the 254 participants, 64.2% were seniors in family medicine (36.4%), endocrinology (36.0%), gynecology (15.8%) and internal medicine (13.8%). Fewer than one-third (28.8%) correctly identified the diagnostic criteria of menopause. Almost all recognized vasomotor symptoms (99.5%), vaginal dryness (96.2%) and mood disturbance (94.3%), but to a lesser extent other symptoms. Inconsistency and critical gaps were identified in responses to competence questions on six case studies. They recalled having occasional (43.2%) or no training (19.4%) in menopause medicine and rated their preparedness to treat menopause widely. A total of 66.2% agreed that training is very important. Variation between specialties was identified.

CONCLUSION

Many physicians recognize the importance of education in menopause management, but their responses revealed critical knowledge gaps that underscored the need for comprehensive, evidence-based menopause management.

A ten year survey of 193 ectopic pregnancies

During the period 1977-86, 193 women underwent surgery for ectopic pregnancy in the Medway Health District. 1 ectopic pregnancy was found for every 233 deliveries, an incidence of 0.43%, with a rising trend. The most common presenting symptom was abdominal pain (96%) and the most frequent physical finding was abdominal tenderness (91%). Past histories of appendicectomy (24%), infertility (19%), use of IUD (15%), and pelvic infection (13%) were elicited. In 95% of the cases, the pregnancy was tubal. 56% of the patients required blood transfusions and there were no maternal deaths. These findings confirm the rising incidence of ectopic pregnancy. During the study period, the diagnosis and management of ectopic pregnancy have changed significantly. The early use of plasma hCG, ultrasonography, and laparoscopy decreases the morbidity and mortality associated with ectopic pregnancy, allowing conservative tubal surgery when indicated.

Percervical intrafallopian bupivacaine instillation to reduce postoperative pain after laparoscopic tubal sterilisation

In a double-blind comparative study of 46 women undergoing laparoscopic tubal sterilization under general anesthesia using Falope ring bands, the group of women (study group, n=22) having 0.5% bupivacaine instilled paracervically had less pain than women given normal saline (control group, n=24) at 1 and 2 hours. The trial group also required narcotic analgesia significantly less often (6/22 vs 19.24) than the control group. The reduction in postoperative pain afforded by this method of administration of bupivacaine allows day case laparoscopic sterilization to be performed with greater confidence.

A randomized controlled trial of the efficacy of transcutaneous electrical nerve stimulation (TENS) versus lidocaine in the relief of episiotomy pain

The aim was to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) and local infiltration of 2% lidocaine in the relief of episiotomy pain measured using a pain visual analog scale (VAS). A randomized, double blind, controlled clinical trial was conducted from January 1 to May 15, 1998, in the Labor-Delivery Complex of Chong Hua Hospital, Cebu City. Skin electrodes were attached to two acupoints. "Shenmen" on the wrist and "hegu" on the hand are acupoints for general pain relief and relaxation. These acupoints were stimulated using a nerve stimulator. Stimulation was started during advance labor and discontinued right after episiorrhaphy. VAS scores were taken during certain periods and compared with VAS scores for those using the conventional method of 2% lidocaine infiltration into the episiotomy site. There were 68 patients who met the inclusion criteria. 38 in the TENS group and 30 in the Control group. The patients profile of the two groups did not differ significantly in terms of age, age of gestation, parity, and length of episiotomy. Among those with VAS score of 5 (bearable), 37% was failed TENS, requiring rescue anesthesia. The proportion of patients with pain during episiotomy and 12 hours after episiorrhaphy showed no significant difference between the two groups. But during episiorrhaphy and 1 hour after episiorrhaphy, the TENS group was superior to the lidocaine group, with p-values of 0.05 (0.0392 and 0.0063, respectively) based on the Mann Whitney U-Test. Ambulation time was shorter in the TENS group. Episiotomy tenderness was nil in the TENS group. There was no swelling and edema in the perineum of patients in the TENS. The need for oral analgesics was likewise much lower in the TENS group. TENS as a form of anesthesia-analgesia cannot totally alleviate episiotomy pain as measured by VAS scoring system, with 37% as failed TENS. The study showed there was a difference only in pain relief during repair, and 1 hour after repair. With TENS being superior to lidocaine, ambulation time was shorter and episiotomy tenderness was nil in the TENS group. Likewise, lesser number of patients requested for oral analgesics in the TENS group.

A randomized controlled trial of oxytocin administered at the end of the second stage of labor versus oxytocin administered at the end of the third stage of labor in the prevention of postpartum hemorrhage

The general objective was to determine the incidence of postpartum hemorrhage when oxytocin was administered at the end of the second stage of labor compared to when oxytocin was administered at the end of the third stage. The specific objectives were to determine the mean amount of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and mean difference in hemoglobin levels. A randomized controlled trial was conducted in a tertiary care training hospital. 130 women with term, singleton, live pregnancies in cephalic presentation who delivered vaginally were included. Patients were randomly allocated to receive oxytocin after the second stage or after the third stage of labor. Oxytocin was administered as a continuous intravenous infusion. The placenta was delivered by controlled cord traction after placental separation. Blood loss was measured by weight, and the corresponding volume was computed. Relative risk was calculated. Incidence of postpartum hemorrhage, volume of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and difference in hemoglobin levels were the main outcome measures. There was a decreased incidence of postpartum hemorrhage (39.66% vs. 48.61%, relative risk [RR] = 0.82, 95% confidence interval [CI] = 0.55-1.21) and less amount of blood loss (557.93 ml vs. 636.84 ml, p = 0.352) when oxytocin was administered at the end of the second stage of labor. There was less need for additional uterotonics (12.07% vs. 13.89%, RR = 0.87, 95% CI = 0.35-2.14), and blood transfusion (5.17% vs. 5.56%, RR = 0.87, 95% CI = 0.22-3.99). There was a smaller mean difference in hemoglobin (16.20 g/dl vs. 20.29 g/dl, p = 0.145). Mean duration of the third stage of labor were comparable (7.93 minutes vs. 7.96 minutes, p = 0.863). However, more patients developed hypotension (3.45% vs. 1.39%, RR = 2.48, 95% CI = 0.23-26.70). All results were not statistically significant. There was no incidence of retained placenta. There is a trend towards a reduction of the risk of postpartum hemorrhage when oxytocin is administered at the end of the second stage of labor. This is not accompanied by an increased risk for any morbidity.

Endometrial adenocarcinoma coexisting with an intrauterine pregnancy: a case report

A rare case of adenocarcinoma of the endometrium discovered during curettage for incomplete abortion was presented and 12 similar cases in the literature were reviewed. In 7 of the 12 patients, a complication of pregnancy led to the discovery of the tumor. In the remaining five, the pregnancy occurred in patients known to have endometrial carcinoma. Most of the cases were well differentiated and minimally invading the myometrium. The pathophysiology, risk factors, diagnosis, treatment, and prognosis were described.

Hemolytic uremic syndrome in pregnancy

A 22-year-old primipara presented with hypertension, anemia, thrombocytopenia and elevated liver enzymes. She was initially managed as a case of HELLP syndrome but, with conventional treatment, the expected improvement did not occur. She later developed intractable oliguria and azotemia. The importance of considering hemolytic uremic syndrome, a distinct part of the spectrum of preeclampsia, separate from but overlapping with HELLP syndrome, was discussed. The need for vigilance in the management was emphasized since the definitive treatment and prognosis differ greatly between the two conditions.