Association of obesity and weight gain with alveolar bone loss: Results of the Northern Finland Birth Cohort 1966 study

AIM

To investigate whether long-term obesity, long-term central obesity and weight gain are associated with alveolar bone loss.

MATERIALS AND METHODS

A sub-population (n = 1318) of the Northern Finland Birth Cohort 1966 was categorized based on body mass index (BMI: normal weight, overweight and obesity) and waist circumference (WC: no central obesity, central obesity) at ages 31 and 46. These categories were combined to define whether the participants stayed in the same categories or passed on to a higher category (weight gain). Alveolar bone level (BL) data were collected at age 46.

RESULTS

The associations of long-term obesity and weight gain with BL ≥ 5 mm were stronger in smokers than in the total population and in never smokers. Males who passed on to higher BMI and WC categories showed a higher likelihood for BL ≥ 5 mm (range in relative risks [RRs] 1.3-2.2) than males who stayed in the same categories (range in RRs 0.7-1.1). The associations with BL ≥ 5 mm were weak or non-existent in females.

CONCLUSIONS

The relation between obesity and periodontal diseases seems more complex than previously presumed. The role of gender and smoking should be taken into account in future studies.

Anticholinergic Burden and Dry Mouth in Middle-Aged People

INTRODUCTION

Anticholinergic burden refers to the cumulative effect of taking 1 or more drugs with anticholinergic properties. At the moment, little is known about the association between the anticholinergic burden and dry mouth.

OBJECTIVES

The objective of this article was to study, whether an anticholinergic burden is associated with dry mouth among middle-aged people.

METHODS

The study population included 1,345 people aged 46 y from the Northern Finland Birth Cohort 1966 (NFBC1966) study, who took part in a clinical medical and dental examination during 2012-2013. Medication data comprised both self-reported drug use and information obtained from the national register. Anticholinergic burden was measured using 10 different anticholinergic scales. Dry mouth was defined on the basis of having either a subjective feeling of dry mouth (xerostomia) or objectively measured low unstimulated or stimulated whole salivary flow rates (hyposalivation). Poisson regression models with robust error variance were used to estimate relative risk (RR). Regression models were adjusted for sex, smoking, diabetes, rheumatoid diseases, depressive symptoms, anxiety, total number of drugs, and antihypertensive drugs.

RESULTS

Approximately 14% of the participants reported having xerostomia and about 2% had hyposalivation. The RRs of different anticholinergic scales for xerostomia varied from 1.05 to 1.68. The scales' RRs were between 0.89 and 2.03 for low unstimulated whole salivary flow (<0.1 mL/min) and between 0.59 and 1.80 for low stimulated whole salivary flow (<0.7 mL/min). Seven of 10 studied anticholinergic scales associated statistically significantly with dry mouth, either with xerostomia or hyposalivation.

CONCLUSION

Most of the anticholinergic scales were associated with dry mouth, either with xerostomia or hyposalivation. There was considerable variation in the strength of the associations between anticholinergic scales and dry mouth.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study suggest that dentists should take notice of the use of drugs with anticholinergic properties and their harmful effects among middle-aged people. Dentists should provide these patients with necessary guidance on how to cope with dry mouth and give them prophylactic measures against oral diseases associated with dry mouth.

The association of medications with sedative properties with oral health behaviour in community-dwelling older people

OBJECTIVES

The objective of this study was to determine whether drugs with sedative properties are related to oral health behaviour-such as frequency of toothbrushing, using toothpaste and dental visits-and oral hygiene, measured by the number of teeth with dental plaque, among community-dwelling older people.

METHODS

The study population consisted of 159 community-dwelling, dentate, non-smoking, older people from the Oral Health GeMS study (Geriatric Multidisciplinary Strategy for the Good Care of Older People study). The data were collected by interviews and clinical examinations during 2004-2005. Sedative properties of drugs were assessed using the sedative load (SL) model. Logistic and Poisson regression models were used to estimate odds ratios/relative risks (OR/RR) and 95% confidence intervals (CI).

RESULTS

After adjusting for confounding factors, SL associated with infrequent toothbrushing (OR 1.72, CI: 0.61-4.89), toothpaste use less than twice a day (OR 3.34, CI: 1.39-8.12), non-regular dental visits (OR 2.28 CI: 0.91-5.30) and the number of teeth with dental plaque (RR 1.20 CI: 1.04-1.39) compared to participants without a SL.

CONCLUSIONS

The results of this study suggest that use of drugs with sedative properties indicates poor oral health behaviour among older people.

Food Consumption and Nutrient Intake in Relation to Denture Use in 55- to 84-Year-Old Men and Women -Results of a Population Based Survey

OBJECTIVE

To study differences in consumption of foods and intake of nutrients attributable to denture status.

DESIGN, SETTING AND PARTICIPANTS

Data from a cross-sectional, nationally representative Health 2000 Survey, subjects aged 55-84 years (n=2,241).

MEASUREMENTS

Denture status (edentulous with full dentures, own dentition with removable dentures, own dentition with no removable dentures) was used as an explanatory variable. The consumption of foods and intake of nutrients was used as an outcome variable and was measured using a validated Food Frequency Questionnaire.

RESULTS

Denture status associated with food choices. Full denture wearers consumed less vegetables (p = 0.013 among men and p = 0.001 among women) and fruits (p = 0.001 among women), more sugary products (p = 0.012 among men and p = 0.008 among women), and their balance in fatty acids was less favourable than among dentate participants. Among dentate participants, the differences between the two groups were small and statistically significant differences were seen mostly in women.

CONCLUSIONS

Wearing full dentures appears to be associated with unhealthier food choices, lower consumption of some foodstuffs and lower intake of certain nutrients when compared to the food choices of dentate persons.

Body mass index and periodontal infection in a sample of non-smoking older individuals

OBJECTIVE

The aim of this study was to investigate the association between BMI and periodontal infection in a sample of non-smoking individuals aged 75 years or older.

SUBJECTS AND METHODS

The study sample included 157 non-smoking dentate persons (110 women, 47 men, mean age 80.6 years) belonging to the Geriatric Multidisciplinary Strategy for the Good Care of Older People study in Kuopio, Finland. The data were gathered by interview together with geriatric and oral clinical examination. The outcome variable was the number of teeth with periodontal pockets measuring 4 mm or more in depth. Poisson regression models were used to estimate relative risk (RR) and 95% confidence intervals (CI).

RESULTS

After adjustment for confounding factors, the relative risk for the number of teeth with deepened periodontal pockets (≥4 mm) was 0.7 (CI: 0.6-0.9) among those with a BMI 25-29.99 and 1.1 (CI: 0.8-1.4) among those with a BMI ≥30, compared with those having a BMI <25.

CONCLUSION

Within the limitations of this study, including small sample size, possibility of confounding and other biases, the results do not provide evidence that elevated body weight would be a risk for periodontal infection among older people.

Efficacy of stabilisation splint treatment on temporomandibular disorders

The evidence supporting the use of stabilisation splints in the treatment of temporomandibular disorders (TMD) is scarce and a need for well-controlled studies exists. The aim of this randomised, controlled trial study was to assess the efficacy of stabilisation splint treatment on TMD. The sample consisted of 80 consecutive referred patients who were randomly assigned to the splint group (n = 39) and the control group (n = 41). Subjects in the splint group were treated with a stabilisation splint, whereas subjects in the control group did not receive any treatment except counselling and instructions for masticatory muscle exercises which were given also to the subjects in the splint group. Outcomes were visual analogue scale (VAS) on facial pain intensity and clinical findings for TMD which were measured at baseline and after 1-month follow-up. The differences in change between the groups were analysed using regression models. Facial pain decreased and most of the clinical TMD findings resolved in both of the groups. The differences in changes in VAS or clinical TMD findings between the groups were not statistically significant. The findings of this study did not show that stabilisation splint treatment in combination with counselling and masticatory muscle exercises has additional benefit in relieving facial pain and increasing the mobility of the mandible than counselling and masticatory muscle exercises alone in a short time-interval.

Metabolic syndrome, periodontal infection, and dental caries

Only a few studies have examined the association of metabolic syndrome with periodontal infection and dental caries. The aim in this study was to examine the association of metabolic syndrome with periodontal infection and dental caries using the European Group for the Study of Insulin Resistance (EGIR) definition and its separate components. This study population consisted of dentate, non-diabetic individuals aged 30 to 64 years (N = 2050) who had never smoked. Relative risks (RR) were estimated with Poisson regression models. Metabolic syndrome was associated with teeth with deepened periodontal pockets 4 mm deep or deeper [adjusted RR 1.19 (95% CI 1.01-1.42)], with pockets 6 mm deep or deeper [adjusted RR 1.50 (95% CI 0.96-2.36)], and carious teeth [adjusted RR 1.25 (95% CI 0.93-1.70)]. The results suggest that metabolic syndrome or some of its components are associated weakly with periodontal infection.

Respiratory effects of exposure to methacrylates among dental assistants

BACKGROUND

Case reports of occupational asthma in dental personnel have been published, but there is little data on the risk of respiratory disorders related to occupational exposure to methacrylates in dental assistants. The objective of this study was to investigate the relation of exposure to methacrylates to occurrence of respiratory symptoms and diseases among dental assistants.

METHODS

A cross-sectional study of female dental assistants from the membership register of the Finnish Association of Dental Hygienists and Assistants was conducted in the Helsinki metropolitan area. A CATI was carried out to collect information on health and exposures. A total of 799 dental assistants participated (response rate 87%).

RESULTS

Daily use of methacrylates was related to a significantly increased risk of adult-onset asthma (adjusted OR 2.65, 95% CI 1.14-7.24), nasal symptoms (1.37, 1.02-1.84), and work-related cough or phlegm (1.69, 1.08-2.71). Nasal symptoms showed a dose-response relation with increasing years of exposure to methacrylates, and those with >10 years of exposure had also increased risk of hoarseness, dyspnoea, and wheezing with dyspnoea. Dental assistants with a history of atopic diseases were particularly susceptible to exposure to methacrylates, the adjusted OR for adult asthma being in this group 4.18 (95% CI 1.02-28.55) and for nasal symptoms 2.11 (1.08-4.19).

CONCLUSIONS

This study provides new evidence that the risk of adult-onset asthma, nasal symptoms and other respiratory symptoms increase significantly with daily use of methacrylates in dental assistants' work. The results suggest that exposure to methacrylates poses an important occupational hazard for dental assistants.

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?

OBJECTIVE

This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was </=4 mm in women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy.

STUDY DESIGN

Transvaginal ultrasonography was performed in 361 women aged >/=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy. If endometrial thickness was </=4 mm, a Papanicolaou cervical smear was performed and the woman was reexamined with transvaginal ultrasonography after 4 and 12 months. Subjects were also instructed to return if they had recurrent bleeding, in which case transvaginal ultrasonography was performed and an endometrial biopsy specimen was obtained. Women with an endometrial thickness >/=5 mm underwent either curettage or endometrial biopsy.

RESULTS

One hundred sixty-three women had an endometrial thickness </=4 mm. In this group one endometrial cancer that was missed by ultrasonography was diagnosed by cervical cytologic examination and two adnexal malignancies were diagnosed by ultrasonography. Endometrial malignancy was diagnosed in 0.6% of the women with an endometrial thickness </=4 mm. Endometrial biopsy was performed because of recurrent bleeding in 6.1% of cases and because of endometrial thickening in 8.1%. No cancer or hyperplasia was subsequently diagnosed among the women with an endometrial thickness </=4 mm. Endometrial cancer was diagnosed in 18.7% of the women with an endometrial thickness >/=5 mm. The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20. 2%.

CONCLUSION

If the false-negative rate of endometrial biopsy techniques is taken into account, then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is </=4 mm. A randomized prospective study is necessary to verify this finding.

Transvaginal ultrasonography at 18-23 weeks in predicting placenta previa at delivery

OBJECTIVE

To evaluate whether transvaginal ultrasonography at 18-23 weeks' gestation is useful in predicting placenta previa at delivery.

DESIGN

We performed transvaginal ultrasonography in addition to routine transabdominal ultrasonography in 3696 consecutive non-selected pregnant women with singleton fetuses and measured the distance from the placental edge to the internal cervical os.

RESULTS

In 57 of 3696 patients (1.5%), the placental edge extended to or over the internal cervical os. In 27 patients (0.7%), the placenta extended > or = 15 mm over the internal cervical os; in these cases the positive predictive value of placenta previa at delivery was 19% (95% CI, 6-38%) with 100% (95% CI, 48-100%) sensitivity. With > or = 25 mm used as the cut-off point, ten cases (0.3%) were screen-positive and the positive predictive value for previa at delivery was 40% (95% CI, 12-74%) and sensitivity was 80% (95% CI, 28-100%). The frequency of placenta previa at delivery in this population was five of 3696 (0.14%, 95% CI, 0.04-0.31%).

CONCLUSIONS

We recommend confirmatory transvaginal ultrasonography if placenta previa is suspected at transabdominal ultrasonography in mid-pregnancy, and reexamination at 26-30 weeks if the placental edge covers the internal cervical os by 15 mm or more.

Safety and efficacy of transdermal estradiol replacement therapy in postmenopausal liver transplanted women. A preliminary report

OBJECTIVE

To determine the safety and efficacy of transdermal estrogen replacement therapy in liver transplanted menopausal women.

SUBJECTS

Thirty-two menopausal women who had at least 6 months earlier undergone liver transplantation, ages from 46-70 years old receiving hormone replacement therapy.

METHODS

The study was an open prospective. The subjects received transdermal estradiol replacement therapy in combination with progestin (EstracombR-Ciba, 50 microg/24 h, 250 microg/24 h) if the uterus was intact, and estradiol alone (EstradermR-Ciba, 50 microg) if the uterus had been removed. The follow-up time was 6 months. Liver function parameters and hemostatic parameters were measured at 0, 3 and 6 months. Gynecological transvaginal ultrasound (TVS) was performed at 0 and 6 months. The efficacy of the hormonal treatment was assessed by measuring serum concentrations of estradiol, estrone, FSH, LH and SHBG, by measuring endometrial thickness with TVS and by recording changes in subjective climacteric symptoms at 0 and 6 months. Safety was assessed by measuring liver enzyme activity, liver synthesis functions and coagulation factors.

RESULTS

Estrogen replacement therapy did not impair any of the liver parameters measured and no thrombotic effect could be detected. Hormonal effects of the regimen prescribed could be verified both biochemically, clinically and by TVS.

CONCLUSION

A clinically desired hormonal effect was achieved by the dose of 50 microg estradiol-17beta. Liver function and hemostatic balance were unaffected by the transdermal hormonal treatment. Immunosuppressive drugs and transdermal estrogen may well be combined.

Increased nuchal translucency as a marker for fetal chromosomal defects

BACKGROUND

Screening for trisomy 21 (Down's syndrome) by measuring maternal serum alpha-fetoprotein, chorionic gonadotropin, and estriol concentrations and then performing chorionic-villus sampling or amniocentesis identifies approximately 60 percent of fetuses with this disorder. We used ultrasonography to detect increased nuchal translucency and cystic hygroma, which are characteristic features of fetuses with chromosomal defects.

METHODS

We performed transvaginal ultrasonography in 10,010 unselected adolescents and women less than 40 years of age with live singleton fetuses at 10 to 15.9 weeks of gestation. Increased fetal nuchal translucency was defined as an area of translucency at least 3 mm in width, and cystic hygromas were defined as septated, fluid-filled sacs in the nuchal region. Subjects whose fetuses had these findings were offered fetal karyotyping. Information on pregnancies, deliveries, and neonates was subsequently obtained from hospital records and national birth and malformation registries.

RESULTS

Nuchal translucency or cystic hygroma was seen in 76 fetuses (0.8 percent), of which 18 (24 percent) had an abnormal karyotype. The sensitivity for trisomies 21, 18, and 13 combined was 62 percent (13 of 21 fetuses), and the sensitivity for trisomy 21 alone was 54 percent (7 of 13 fetuses).

CONCLUSIONS

The use of transvaginal ultrasonography to detect increased nuchal translucency and cystic hygroma is a sensitive test for fetal aneuploidy. It can be done earlier in pregnancy than serum screening, and it decreases the subsequent need for chorionic-villus sampling or amniocentesis.

Disappearance of human chorionic gonadotropin and its alpha- and beta-subunits after term pregnancy

We have used high-specificity and precision immunofluorometric assays to measure the elimination half-times of human chorionic gonadotropin (hCG), hCG alpha, and hCG beta in serum over 21 days after delivery in six women with term pregnancies. Baseline concentrations and half-times were calculated with the use of a curve-fitting algorithm for multiexponential decay. In contrast to the two-component model, a three-component exponential function with baseline provided a fit for which predicted values could not be distinguished from the observed values by analysis of variance. Median half-times were 3.6, 18.0, and 53.0 h for hCG; 1.0, 23.4, and 194 h for hCG beta; and 0.6, 6.2, and 21.9 h for hCG alpha. The mean ratio of hCG alpha to hCG decreased rapidly from 36.9% to 3.3% on day 3; thereafter it increased to 64.3% 21 days after delivery because of a higher baseline concentration of hCG alpha. hCG beta had the slowest total elimination rate, and the ratio of hCB beta to hCG in serum increased from 0.8% before delivery to 26.7% after 21 days. If the metabolism of hCG and hCG beta is similar in patients with trophoblastic disease, the ratio of hCG beta to hCG must be evaluated with caution in samples taken several days after initiating therapy. We conclude that the disappearance of hCG beta from plasma is slower than previously recognized and that the ratios of hCG beta or hCG alpha to intact hCG vary as a function of postpartum time. Such information may be important in clinical studies of pregnancy disorders.

Endometrial sonographic and histologic findings in women with and without hormonal replacement therapy suffering from postmenopausal bleeding

OBJECTIVES

To evaluate, in women with postmenopausal bleeding, the effect of hormonal replacement (HRT) therapy on the endometrial thickness as measured by transvaginal sonography in relation to endometrial histology.

METHODS

1110 women with sequential/progestin treatment (E + P) (n = 202), with Estriol treatment (n = 149) or without HRT (n = 759) and postmenopausal bleeding were examined by transvaginal sonography (TVS) prior to curettage, with special reference to the relation of endometrial thickness to its histopathology.

RESULTS

The distribution of endometrial pathology was different in those women with E + P and Estriol compared with those without HRT. Endometrial pathology was found most frequently in women with an endometrium exceeding 8 mm in thickness. Furthermore, the incidence was found to increase with increasing endometrial thickness in all treatment groups. Atrophy was found significantly more often in women without HRT. Hormonal effects on the endometrium were found significantly more often in women with E + P and Estriol. Endometrial hyperplasia was found most commonly in women with Estriol in the thickness group 5 8 mm (P < 0.001) as compared to those with HRT and without HRT. Endometrial cancer occurs most in women without HRT, in those women with an endometrium exceeding 8 mm in thickness as compared both to the E + P (P < 0.001) group and to the Estriol (P < 0.001) group. Endometrial cancer did not occur in any woman (with E + P, Estriol or without HRT) with an endometrial thickness of < or = 4 mm.

CONCLUSIONS

TVS is of value for excluding endometrial pathology in women with HRT and postmenopausal bleeding. The distribution of endometrial findings and histopathological diagnosis in women with abnormal postmenopausal bleeding was different in women with E + P than in women without HRT. Furthermore, the cut-off for excluding endometrial abnormalities is the same in both groups i.e. < or = 4 mm.

Diagnosis of placenta previa by transvaginal sonographic screening at 12-16 weeks in a nonselected population

OBJECTIVE

To evaluate the clinical significance of placenta previa at 12-16 weeks' gestation found by transvaginal sonographic screening.

METHODS

An unselected population of 6428 pregnant women was scanned by transvaginal sonography during 1993-1994 to assess the gestational age and to diagnose major fetal anomalies. The location of the placenta was also recorded systematically. If the edge of the placenta extended over the internal cervical os, this distance was measured with electronic calipers.

RESULTS

In 156 of 6428 patients (2.4%), the placental edge extended 15 mm or more over the internal cervical os at 12-16 weeks' gestation. Eight of these patients had placenta previa at delivery. Using this criterion at screening, two cases of placenta previa at delivery were missed. The frequency of placenta previa at delivery in this nonselected population was ten of 6428 (0.16%).

CONCLUSIONS

The likelihood of placenta previa at delivery is 5.1% (95% confidence interval 2.2, 9.9) if the placenta extends at least 15 mm over the internal cervical os at 12-16 weeks' gestation.

Ectopic pregnancy after in-vitro fertilization is characterized by delayed implantation but a normal increase of serum human chorionic gonadotrophin and its subunits

We studied the dynamics of serum human chorionic gonadotrophin (HCG) and its free alpha (HCG alpha) and beta (HCG beta) subunits in 49 early pregnancies achieved by in-vitro fertilization (IVF) and embryo transfer. Of the 49 early pregnancies, nine were normal singleton pregnancies, 11 were twin pregnancies, 11 were ectopic, eight ended in a clinical (spontaneous) abortion and 10 ended in a preclinical abortion. The HCG, HCG alpha and HCG beta concentrations in serum were measured on days 12, 19 and 26 after embryo transfer. Most ectopic pregnancies could be distinguished from singleton (and twin) pregnancies on the basis of low HCG concentrations by 12 days after embryo transfer, but clinical abortions could not be distinguished from singleton pregnancies. In general, the measurement of HCG alpha and HCG beta and the molar ratios of the various forms provided only marginal additional value to that obtained from HCG, but on days 19 and 26 after embryo transfer HCG alpha was the most sensitive indicator of a normal pregnancy after IVF and embryo transfer. We conclude that in ectopic pregnancies the concentrations of HCG, HCG alpha and HCG beta increase as expected but 1.5 days later than in normal pregnancies. This appears to be the result of a delay in implantation.

Low-dose oral methotrexate with expectant management of ectopic pregnancy

OBJECTIVE

To investigate recovery times and need for laparoscopy in women with ectopic pregnancy who were treated for 5 days 2.5 mg/day of oral methotrexate or placebo.

METHODS

Sixty women with ectopic pregnancy among patients of an outpatient clinic specializing in early pregnancy disorders were selected for medical treatment in a double-blind, placebo-controlled study. The diagnosis was made by transvaginal sonography and serum hCG determinations, either at admission or after repeated examinations. Women were recruited for the study if they had mild symptoms: the hCG increase was less than 50% within 2 days, the diameter of the ectopic pregnancy was less than 40 mm, there were no signs of intra-abdominal bleeding by transvaginal sonography, and there were no secondary reasons for laparoscopy. Either 2.5 mg of methotrexate or placebo was given orally for 5 days. Serum hCG was determined after 2 days, and hCG, red blood cell count, white blood cell count, platelet count, and serum glutamic-oxaloacetic transaminase were measured; transvaginal sonography was performed after 5 and 12 days. Expectant management was continued individually with check-ups at 1-3-week intervals. Laparoscopy was performed if the patient developed abdominal pain or intra-abdominal hemorrhage, as seen by transvaginal sonography. Statistical analysis was by paired or unpaired t test, Mann-Whitney U test, regression analysis, and repeated measures analysis of variance.

RESULTS

Seventy-seven percent of the patients recovered without the need for laparoscopy in both groups, and there were no significant differences in recovery times or the need for laparoscopy between groups.

CONCLUSION

Oral methotrexate, 2.5 mg for 5 days, does not appear to be more effective than placebo in the treatment of ectopic pregnancy in women eligible for expectant management.

Clinical features of primary ovarian failure caused by a point mutation in the follicle-stimulating hormone receptor gene

The recent finding that a mutation in the FSH receptor gene causes ovarian dysgenesis prompted the present study to determine the phenotype caused by this mutation. Twenty-two patients with ovarian dysgenesis and a 566C-->T mutation in the FSH receptor gene (designated FSH-resistant ovaries or FSHRO) were compared with 30 clinically similar patients with ovarian dysgenesis (designated ODG) who did not have this mutation. The genealogical studies suggested a founder effect of the FSH receptor gene mutation in Finland. Clinically, both groups of patients were characterized by primary or early secondary amenorrhea, variable development of secondary sex characteristics, and high serum levels of FSH and LH. Notable differences were observed in median adult height (FSHRO patients were shorter) and the occurrence of follicles judged by transvaginal sonography (observed in 6 of 8 FSHRO vs. 1 of 11 ODG) and ovarian histology (present in all 9 FSHRO vs. 1 of 4 ODG). These findings suggest that a subset of ovarian dysgenesis patients with the FSH receptor mutation 566C-->T is pathogenetically distinct, possibly due to residual receptor activity, and that these patients can be tentatively identified by demonstrating the presence of ovarian follicles and confirmed by mutation analysis.

Tubal artery blood flow in evaluation of tubal pregnancy

OBJECTIVE

To evaluate whether the assessment of tubal blood flow can indicate the side of the total pregnancy.

METHODS

Using transvaginal color Doppler ultrasonography, we measured blood flow in the total arteries on both sides in 46 women with early ectopic pregnancy. We compared the resistance index (RI) and pulsatility index (PI) values of the tubal artery flow on the tubal pregnancy side to the contralateral side.

RESULTS

The Resistance index (RI) and Pulsatility index (PI) values were lower at the tubal pregnancy side in 70% and 61%, respectively, when compared with the contralateral side. However, in the mean values of RI and PI the difference between the sides was not statistically significant. During the follow up in cases with spontaneous resolution between-side difference was often subjected to changes.

CONCLUSION

Assessment of tubal blood flow by using transvaginal color Doppler sonography to the evaluation of the side of tubal pregnancy has limited clinical value.

Cost-effectiveness of one-stage ultrasound screening in pregnancy: a report from the Helsinki ultrasound trial

The objective of this study was to evaluate, in a controlled clinical trial, the costs of standardized one-stage ultrasound screening in pregnancy in relation to the reduction in perinatal mortality. A trial population of 9310 pregnant women was randomly allocated to ultrasound screening or a control group. Two obstetric hospitals and 64 recruiting antenatal health centers were involved. The costs included actually realized costs, i.e. positive costs, and gains, i.e. negative costs, resulting from lower health-care use. Cost-accounting data were obtained by a questionnaire to all attenders and measurements at the screening, and later complemented by a questionnaire to a random sample of 534 screened women. Internal accounting and other hospital data, national statistics and health-market sources were also used. The actually realized cost of each avoided perinatal death was FIM 84 378 ($21,938), while the net overall estimate combining all positive and negative costs showed a cost saving of FIM 65 680 ($17,077). The total positive unit cost of ultrasound screening was FIM 393 ($102). Longer ultrasound examination time and more numerous advanced examinations were rewarded by clearly fewer perinatal deaths and a better cost-effectiveness ratio. One-stage second-trimester ultrasound screening is cost-effective when all significant costs and effects are taken into account.

Failure of creatine kinase to predict ectopic pregnancy

OBJECTIVE

To investigate serum creatine kinase (CK) levels in pregnant women with ectopic pregnancy (EP), spontaneous abortion, and normal pregnancy with comparable serum hCG concentrations.

DESIGN

A retrospective, case-controlled study.

SETTING

Helsinki University Central Hospital, Helsinki, Finland.

PATIENTS

Forty-four patients with a suspicion of EP of which 15 had laparoscopically confirmed tubal pregnancies; 15 had a spontaneous abortion, a blighted ovum, or a missed abortion; and 14 patients a normal intrauterine pregnancy.

INTERVENTIONS

The diagnosis was made by transvaginal sonography and serum hCG determinations either at admission or after repeated examinations. Ectopic pregnancy was confirmed and treated by laparoscopy.

MAIN OUTCOME MEASURES

Serum CK and hCG levels.

RESULTS

No significant differences in CK levels were observed between the groups by one-way analysis of variance and no correlation was found between serum CK and hCG levels within any group.

CONCLUSIONS

Creatine kinase does not appear to be useful in the diagnosis of early EP.

Uterine findings by transvaginal sonography during percutaneous estrogen treatment in postmenopausal women

OBJECTIVES

To evaluate the effect of hormone replacement treatment (HRT) with percutaneous estradiol and cyclical peroral medroxyprogesterone acetate (MPA) every month or every third month on the uterus and endometrium of postmenopausal women.

METHODS

Uterine size and endometrial thickness were measured by transvaginal sonography in 159 postmenopausal women before HRT, and after 6 and 12 months on HRT during 9-12 days of the MPA administration periods.

RESULTS

During HRT, uterine size and endometrial thickness increased. The percentage increase in uterine diameter varied between 3.8% and 19.6%, and endometrial thickness varied between 28.7% and 76.4%, being greater in the group receiving MPA every third month than in the groups receiving MPA every month. Myomas grew during the first 6 months on HRT but increased no further during the next 6 months on HRT.

CONCLUSIONS

The increases in uterine size, myomas and endometrial thickness during HRT were moderate and not problematic and occurred mainly during the first 6 months on HRT.

Gonadal function and morphology in non-cirrhotic female alcoholics: a controlled study with hormone measurements and ultrasonography

OBJECTIVE

To study the occurrence and mechanisms of gonadal dysfunction in women with alcohol abuse.

DESIGN

Prospective study.

SETTING

Helsinki University Central Hospital.

SUBJECTS

Fifteen consecutive chronic female alcoholics without liver cirrhosis admitted for withdrawal treatment, were studied after cessation of alcohol intake. Twelve women had regular menstrual cycles, two appeared to be menopausal and one had hypothalamic amenorrhoea. The women with regular cycles were compared with eleven healthy controls.

INTERVENTION

Blood was sampled for hormone measurements three times on cycle days 5 to 7, 11 to 14, and 19 to 22, and ultrasonography was performed on the same days as the first two hormonal studies.

MAIN OUTCOME MEASURES

Serum LH, FSH, prolactin, estrone, estradiol, progesterone, testosterone, androstenedione, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), the ovarian volume, the follicular diameter, the endometrial thickness.

RESULTS

During the luteal phase of the menstrual cycle the serum concentration of testosterone was 65% (p < 0.01) higher and that of progesterone 23% (p > 0.05) lower in patients than in controls. During the follicular phase serum DHEAS level was decreased by 39% (p < 0.05) in patients. Otherwise the serum concentrations of the hormones studied were similar in patients and in controls. As assessed by ultrasonography, patients and controls did not differ with regard to size of the ovaries, follicle development, or the endometrial thickness.

CONCLUSIONS

Even heavy alcohol use has only minor permanent effects on ovarian function, at least until development of liver cirrhosis.

Transvaginal sonography and serum hCG in monitoring of presumed ectopic pregnancies selected for expectant management

We studied sonographic findings and levels of human chorionic gonadotropin (hCG) in 71 patients with a presumed ectopic pregnancy, recruited for conservative management, to find out whether these parameters may be useful in monitoring treatment. Patients were selected on the basis of decreasing hCG levels, minimal symptoms and an adnexal mass, suggestive of ectopic pregnancy, of < or = 5 cm at transvaginal sonography. In 49 (69%) patients the ectopic pregnancy resolved spontaneously: the adnexal mass resolved significantly more slowly than did hCG levels. In 22 (31%) of the cases laparoscopy was required after an average of 9 days, because of worsening clinical symptoms. The initial size of the ectopic pregnancy did not significantly differ between the two groups, but it increased constantly in the laparoscopy group. The number of patients with free pelvic fluid also increased significantly in the laparoscopy group, whereas blood flow patterns at admission and during follow-up did not differ between the two groups. A decrease in ectopic pregnancy size at day 7 had a sensitivity of 84% and a specificity of 100% in predicting spontaneous resolution. Transvaginal sonography monitoring appears useful in recognizing the ectopic pregnancies most likely to resolve spontaneously without complications.

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding--a Nordic multicenter study

OBJECTIVE

The purpose of this study was to use transvaginal ultrasonographic measurements to find the thickness of the endometrium below which the risk of endometrial abnormality in women with postmenopausal bleeding is low.

STUDY DESIGN

This multicenter study was carried out at eight clinics in four Nordic countries. The study included 1168 women with postmenopausal bleeding scheduled for curettage Before the curettage was performed, the thickness of the endometrium was measured with transvaginal ultrasonography. The measurement included both endometrial layers (double-layer technique). The transvaginal ultrasonographic measurement was compared with the histopathologic diagnosis of the curettage specimens.

RESULTS

In women with atrophic endometrium the mean endometrial thickness (+/- SD) was 3.9 +/- 2.5 mm. The corresponding figures for women with endometrial cancer were 21.1 +/- 11.8 mm. No malignant endometrium was thinner than 5 mm. In 30 women (2.8%) it was not possible to measure the thickness of the endometrium; one of these women had endometrial cancer. The 95% confidence limit for the probability of excluding endometrial abnormality was 5.5% when the endometrial thickness was < or = 4 mm as measured by transvaginal ultrasonography.

CONCLUSION

The risk of finding pathologic endometrium at curettage when the endometrium is < or = 4 mm as measured by transvaginal ultrasonography is 5.5%. Thus in women with postmenopausal bleeding and an endometrium < or = 4 mm it would seem justified to refrain from curettage.

Oral contraceptive containing natural estradiol for premenopausal women

An open multicenter trial was performed in six centers in Finland to study the efficacy, safety and acceptability of a new biphasic oral contraceptive pill containing natural estradiol and cyproterone acetate. The participants were 288 women with a mean age of 39.3 +/- 3.4 years (range 30-49) who were willing to use the new pill as their only contraceptive method. In total, 23% of the women were smokers. The cumulative experience was 2800 treatment cycles during the first year. The net 12-month continuation rate was 63%. One pregnancy occurred in a woman who lost 5 tablets in the second treatment cycle, which gives a 12-month cumulative pregnancy rate of 0.4%. Serum progesterone values, determined twice during the third treatment cycle, showed ovulation inhibition in 95% of women. There were no serious side effects. Intermenstrual bleeding was recorded by 35.5% and 24.5% of women at 3 and 12 months, respectively. The bleedings became scantier in most women and dysmenorrhoea disappeared. No changes were observed in total and high density lipoprotein cholesterol concentrations after 1 year. With the exception of intermenstrual spotting, the efficacy, safety and acceptability of the new pill was almost as good as that of the modern low dose oral contraceptives. This is the first pill containing natural estradiol that has gained clinical acceptance and which can also be prescribed for smokers over 35 years old until the climacteric.

Serum CA 125 levels and sonography in the pre-operative assessment of myometrial invasion of endometrial cancer

OBJECTIVE

To assess the value of elevated serum CA 125 levels and ultrasonography in predicting deep myometrial invasion of endometrial cancer.

DESIGN

We assessed pre-operatively serum CA 125 levels and myometrial invasion by ultrasonography in women undergoing laparotomy because of endometrial cancer. The results were compared with histological determination of myometrial invasion of endometrial cancer. Invasion was classified as superficial (less than one-half of myometrium involved) or deep (more than one-half of myometrium involved).

SETTING

University hospital.

SUBJECTS

Seventy-eight women with a histologically proved endometrial carcinoma confined to the uterus: nine had Stage IA disease, 45 Stage IB, five Stage IC, one Stage IIA, four Stage IIB and 14 Stage IIIA. The myometrial invasion was found to be superficial in 57 (73%) patients and deep (more than half) in 21 (27%), respectively.

RESULTS

CA 125 levels were above 35 iu/l in 17 (21.8%) of 78 patients: nine (42.8%) of 21 with deep myometrial invasion and eight (14%) of 57 with superficial invasion (P < 0.01). The positive predictive value of an elevated CA 125 level for deep myometrial invasion was 52.9% and the negative predictive value 80.3%. Sonography correctly estimated invasion in 69 cases (88.5%). Deep invasion was assessed by ultrasound with a significantly (P < 0.01) higher sensitivity than CA 125 (95.2% vs. 42.8). Positive and negative predictive values for deep myometrial invasion of sonography were 71.4% and 98%, respectively.

CONCLUSION

Ultrasonography was more accurate than serum CA 125 levels in predicting myometrial invasion of endometrial carcinoma.

Transvaginal sonography and hysteroscopy in postmenopausal bleeding

We compared transvaginal sonography and hysteroscopy with dilatation and curettage findings in 45 women with atypical postmenopausal bleedings. The histological diagnosis was atrophy in eight (17.8%) women, hormonal effects in 14 (31.1%), endometrial polyp in 19 (42.2%) and adenocarcinoma in four (8.8%). Hysteroscopy detected 16 (78.9%) of the 19 cases with polyps and two of the four with carcinoma. Sensitivity and specificity for endometrial pathology were 86.9% and 91.7% respectively. A polyp was directly diagnosed by transvaginal sonography in 13 (57.9%) women and an infiltrative endometrial cancer in two. Sensitivity and specificity for endometrial pathology were 73.9% and 95.7% respectively. All but one case of endometrial pathology were found when the endometrium (both layers) was thicker than 5 mm. Thus, an endometrial thickness of > or = 5 mm had a sensitivity of 95.7%, a specificity of 45.5% and a positive predictive value of 64.7% for endometrial pathology. This study shows that transvaginal scanning allows detection of an endometrial pathology in the vast majority of cases and it may be used as the first diagnostic step in the investigation of women with atypical postmenopausal bleeding.

Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy

OBJECTIVE

To study serum hCG dynamics in patients with ectopic pregnancy (EP) selected for expectant management.

DESIGN

A prospective observational study.

SETTING

Helsinki University Central Hospital, Helsinki, Finland.

SUBJECTS

One hundred eighteen patients, who were selected for expectant management among 493 patients with EP.

INTERVENTIONS

Patients were examined every 1 to 3 days using transvaginal sonography and serum hCG determinations until hCG values < 10 IU/L (conversion factor to SI unit, 1 IU/L = 2.93 pmol/L) were reached. Laparoscopy was performed if the patient developed abdominal pains or intra-abdominal hemorrhage as revealed by sonography.

MAIN OUTCOME MEASURE

Serum hCG level.

RESULTS

The median gestational age at the start of follow-up in patients with a spontaneous resolution was 44 days and in patients requiring laparoscopy was 48 days. The success rate for a spontaneous resolution was 88% when the initial hCG level was < 200 IU/L but only 25% at levels > 2,000 IU/L. In the 77 patients with a spontaneous resolution, the initial median hCG concentration was 374 IU/L (range, 20 to 10,762 IU/L) and it decreased to normal in 4 to 67 days (mean, 20 days). In the 41 patients requiring laparoscopy the median initial hCG concentration was 741 IU/L (range, 165 to 14,047 IU/L); a normal level was reached in 3 to 43 days (mean, 12 days) after operation. Follow-up period before operation was 1 to 24 days (mean, 9 days). Laparoscopy was indicated in two thirds of the patients with a serum hCG level > 64% of the initial value after 7 days of follow-up.

CONCLUSIONS

Spontaneous resolution of EP correlated with a low and rapidly decreasing hCG level.

Early screening for ectopic pregnancy in high-risk symptom-free women

We screened 225 symptom-free pregnant women at increased risk for ectopic pregnancy with transvaginal sonography and human chorionic gonadotropin (hCG) assays. Among 55 (24.4%), who proved to have an ectopic pregnancy, 46 (84%) cases were diagnosed at the initial screening at a median of 37 days of gestation, and the rest at repeated scans. The false-positive rate was 1.2%. Early diagnosis prevented tubal rupture, substantial haemorrhage, and the need for emergency care, allowing elective treatment. Such early surveillance reduced the risk of complications and facilitated treatment, and should be offered to at-risk women.

Fetal anomalies in a controlled one-stage ultrasound screening trial. A report from the Helsinki Ultrasound Trial

The aim of the study was to compare whether systematic strictly timed screening of all pregnancies would improve the detection of major fetal anomalies. All pregnant women (95%) from a certain area were randomly allocated for one ultrasound screening examination between the 16th and 20th weeks of gestation. Otherwise the screening (N = 4691) and control groups (N = 4619) received the same antenatal care. Screening included a systematic search for fetal anomalies. In the screening group, 40% of major fetal anomalies were detected in the screening, and 11 abortions were induced because the malformation was either lethal or severely handicapping. In the control group, 77.0% of participants had ultrasound examination any time during pregnancy. By ultrasound 13 (27%) major fetal anomalies were detected, only two of these before the 21st week of gestation. Screening detected most of the anomalies of the central nervous system and genitourinary system and cases with multiple anomalies, but was less satisfactory in detecting the anomalies of the heart and gastrointestinal tract. The perinatal mortality rate was 4.2 per 1000 in the screening group and 8.4 per 1000 in the control group (p = 0.013). The detection of major fetal anomalies in ultrasound screening can reduce perinatal mortality. A systematic search for fetal anomalies should be included in the ultrasound screening of all pregnancies.

Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease

OBJECTIVE

To evaluate transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease (PID).

METHODS

We studied 51 outpatients with a mean age of 26.8 years (range 16-52) who had a history of low abdominal pain, negative pregnancy test, and no gynecologic procedures performed during the last month. Endometrial biopsy was used for the histopathologic diagnosis. The presence of plasma cell endometritis was used as the criterion standard for the diagnosis of PID. Sonography was performed before biopsy in a blinded fashion without knowledge of the clinical findings and laboratory results except for the pregnancy test. Repeat pelvic and ultrasound examinations were performed 4 weeks after antimicrobial therapy.

RESULTS

Endometrial biopsy revealed plasma cell endometritis in 13 cases (25%). Thickened fluid-filled tubes were seen in 11 of 13 patients (85%) with plasma cell endometritis and in none of those without. Other sonographic findings associated with plasma cell endometritis were polycystic-like ovaries and free pelvic fluid. A sonogram suggestive of PID, ie, thickened fluid-filled tube with or without free pelvic fluid, had a sensitivity of 85% and a specificity of 100% for the diagnosis of plasma cell endometritis. None of the patients with a normal sonogram or simple cyst had plasma cell endometritis. Repeat examination after 4 weeks showed that the sonographic findings had resolved in 60% of the patients who had had histologic evidence of infection.

CONCLUSION

Transvaginal sonography can facilitate the outpatient management of patients with suspected PID.

Expectant management of ectopic pregnancy

OBJECTIVE

To evaluate expectant management in selected cases of ectopic pregnancy.

METHODS

Transvaginal sonography and estimation of serum hCG concentrations were used in the evaluation and follow-up of ectopic pregnancy. Entry criteria for expectant management were: decreasing level of serum hCG, diameter of the ectopic pregnancy less than 4 cm, and no signs of rupture or acute bleeding by vaginal sonography.

RESULTS

Expectant management was studied in 83 patients, representing 26% of all ectopic pregnancies during a 2-year period. In 57 patients (69%), spontaneous resolution occurred, corresponding to 18% of all ectopic pregnancies. Laparoscopy was performed in 26 because of clinical symptoms or a rise in hCG level after expectant management for 1-18 days. One patient had a tubal rupture requiring tubal resection by laparoscopy. No serious complications occurred. With increasing experience, the rate of expectant management and spontaneous resolution increased during study period.

CONCLUSION

Expectant management with repeated vaginal sonography and estimations of serum hCG concentrations is a useful form of treatment for ectopic pregnancy in selected cases.

Conservative treatment of ectopic pregnancy

As a conservative nonsurgical treatment of an early ectopic pregnancy, local prostaglandin, parenteral or local methotrexate, local hyperosmolar glucose, and also expectant management have been used successfully in selected cases. The success rate of conservative treatment has been 71%-100% and that of tubal patency after different kinds of conservative treatment 72-93% of patients. In the present study of expectant management in early ectopic pregnancy in patients with decreasing serum hCG levels, spontaneous resolution was observed in 64.6% of patients and in the total series of 207 ectopic pregnancies in 15.0% of patients. Expectant management of early ectopic pregnancy is recommended when emergency surgery is not needed on admission and the serum hCG level is decreasing as noted in two consecutive estimations with an interval of 1-2 days.

Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level of 1000 IU/l (IRP)

The diagnostic value of vaginal sonography in combination with a discriminatory serum hCG level of 1000 iu/l (International Reference Preparation) was tested prospectively in 200 pregnant women suspected of having an ectopic pregnancy. An ectopic pregnancy was diagnosed in 68 women (34%), a miscarriage in 56 (28%) and a normal pregnancy in 76 (38%). On admission, an intrauterine sac was seen in 89% of the intrauterine pregnancies, but in none of the ectopic pregnancies. Detection of an adnexal mass separate from the ovaries was diagnostic of ectopic pregnancy with a sensitivity of 93%, a specificity of 99%, a positive predictive value of 98% and a negative predictive value of 96%. In 19 patients (9%) the initial sonogram was non-diagnostic and the final diagnosis was obtained after a repeated scan within 6 days. Five of these women had an ectopic pregnancy, 12 a miscarriage and two a normal pregnancy. On admission the hCG level exceeded 1000 iu/l in 77% of all patients and in 67% of those with ectopic pregnancies. In patients with an initial level exceeding 100 iu/l, an intrauterine sac was found in all the intrauterine pregnancies but in none of the ectopic pregnancies. The use of this threshold in combination with sonographic detection of an adnexal mass was diagnostic of ectopic pregnancy with a sensitivity of 97%, a specificity of 99%, a positive predictive value of 98% and a negative predictive value of 98%.

Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy. The Helsinki Ultrasound Trial

During a 19-month period, 95% of all pregnant women in the greater Helsinki area, Finland, entered a study to compare one-stage ultrasonography screening with selective screening according to antenatal hospital use, obstetric procedures, and fetal outcomes. Of 9310 women who entered the trial, 4691 were randomly allocated to ultrasound screening between the 16th and 20th gestational weeks and 4619 to follow-up only. Screened and control groups otherwise had the same antenatal care, which included ultrasonography according to usual practice. Screened women made fewer visits to the antenatal outpatient clinic than did women in the control group (2.3 vs 2.6). There were no differences in the number of labour inductions or mean birthweights in the two groups. Perinatal mortality was significantly lower in the screened than in the control group (4.6/1000 vs 9.0/1000); this 49.2% reduction was mainly due to improved early detection of major malformations which led to induced abortion. All twin pregnancies were detected before the 21st gestational week in the screening group compared with 76.3% in the control group; perinatal mortality in the small series of twins was 27.8/1000 vs 65.8/1000, respectively.

Ultrasound findings in uterine mixed müllerian sarcomas and endometrial stromal sarcomas

Sonographic findings in five cases of mixed mullerian tumors and two cases of endometrial stromal sarcoma which were evaluated before surgery for staging are reviewed. Assessment of myometrial invasion was in agreement with surgical findings in five cases; in the two other cases invasion was overestimated. The echo pattern of these tumors presented some peculiarities. In five patients, four with mixed mullerian tumors and one with endometrial stromal sarcoma, a heterogenous pattern with high-intensity and hypoechoic areas scattered in the myometrium was seen. In the other two cases the sonographic picture was indistinguishable from that of leiomyomas. Sonography is an accurate imaging technique for preoperative staging of uterine sarcomas. If an heterogenous echo pattern of the uterus as described is found at sonography, sarcoma should be suspected and laparotomy performed urgently.

Comparison of abdominal and vaginal sonography in suspected ectopic pregnancy

We compared the accuracy of vaginal sonography in 100 women suspected of having an ectopic pregnancy, in whom a living fetus was not seen by abdominal sonography. Vaginal sonography provided more useful diagnostic information in 44% of the cases, 31% of the ectopics and 52% of the intrauterine pregnancies. Among the 39 ectopic gestations, vaginal scanning was more accurate than abdominal scanning in detecting the ectopic pregnancy (90 versus 80%) and cul-de-sac fluid (77 versus 46%), in identifying an ectopic gestational sac (69 versus 44%), and in diagnosing a tubal pregnancy as unruptured (76 versus 50%). Only one false-positive diagnosis was made by each method of scanning. Among the 61 intrauterine pregnancies, vaginal scanning allowed a more accurate detection of the content of the sac (fetus/yolk sac) in 49% of the cases. In two women, normal intrauterine sacs of 2 and 2.5 mm were detected only by vaginal scanning, at hCG levels of 740 and 840 IU/L (First International Reference Preparation), respectively. Vaginal scanning appears important for early diagnosis of intrauterine pregnancy and more accurate diagnosis of ectopic pregnancy.

Contribution of vaginal scanning to sonographic evaluation of endometrial cancer invasion

Vaginal sonography was compared to abdominal sonography in predicting myometrial invasion in 23 women (mean age 59 +/- 9 years) undergoing hysterectomy due to endometrial cancer. Vaginal scanning prediction corresponded to histological findings in 87% (20/23) of the cases. In 2 cases the degree of invasion was underestimated and in 1 case overestimated by vaginal sonography. Abdominal sonography was accurate in 78% (18/23) of the cases. Vaginal scanning also improved the sonographic visualization of endometrium and cervical canal. However, in one case a superficial invasion of the cervix was missed by both methods of scanning. Furthermore, in another patient an ovarian cyst of 5 cm located in the upper pelvis was seen by abdominal but not vaginal sonography. We suggest that a sonographic work-up to assess endometrial cancer spread should include both methods of scanning.

Preoperative sonographic evaluation of endometrial cancer

Preoperative sonography was performed in 93 patients with a histologic diagnosis of endometrial cancer. Uterine volume was enlarged (mean, 164 +/- 143.7 cm3; range, 25 to 800) but did not significantly correlate with the degree of myometrial invasion. Endometrial echoes were identified in 93.5% of the cases. A significant correlation (p less than 0.01, Newman-Keuls test) was found between endometrial echoes volume and myometrial invasion. Myometrial invasion was correctly predicted by sonography in 80% of the cases. Polypoid intraluminal growth was the most common factor affecting sonographic accuracy. Sonographic staging was accurate in 91% of the cases. Sonography appears to be an efficient, economic, and practical tool for clinical staging of endometrial cancer.

New natural oestradiol/cyproterone acetate oral contraceptive for pre-menopausal women

Fifty (50) healthy ovulating women aged between 35 and 47 yr (mean age 39) were randomly allocated to one of two groups treated with biphasic formulations of either oestradiol valerate/cyproterone acetate (Group A) or oestradiol valerate/norethisterone (Group B). A double-blind design was used during the first 6 mth of treatment. In Group A, 21 out of 26 women (81%), and in Group B, 16 out of 24 (67%) completed the first year of treatment. No pregnancies occurred. The mid-cycle serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) peaks were suppressed, but there were no differences between the pretreatment serum oestradiol values and those observed during the treatment cycles. The serum progesterone values indicated that only one ovulatory cycle occurred during the first year in Group A, while there were 11 in Group B. Ultrasonic studies revealed follicular growth during treatment in both groups, most follicles becoming atretic or persistent without ovulation. No significant changes were observed in 11 coagulation factors studied in 16 women in Group A. Serum total cholesterol decreased by about 10% in both groups. In Group A bleeding became scantier and dysmenorrhoea disappeared. The incidence of spotting varied between 30% and 40%, but it is important to note that the total number of bleeding days per cycle fell. The oestradiol valerate/cyproterone acetate combination was thus found to inhibit ovulation, provide tolerable cycle control and to be free from adverse metabolic side effects.

Ovarian stimulation during gonadotropin treatment after hCG administration monitored by ultrasound and serum estradiol and progesterone

Ovarian volumes, measured with ultrasound, and serum estradiol and progesterone concentrations were studied during gonadotropin treatment cycles 1 week after hCG administration in 23 patients, of whom nine had polycystic ovarian syndrome (PCO), eight oligomenorrhea or amenorrhea corresponding to WHO group II (OMG), and six hypogonadotropic amenorrhea corresponding to WHO group I (HGT). The ovarian volumes were greater in the PCO and HGT groups than in the OMG group. The serum estradiol and progesterone concentrations correlated more closely with ovarian volumes in the HGT group than in the PCO and OMG groups. The present study failed to demonstrate a lower risk of hyperstimulation in the HGT group in comparison with the PCO and OMG groups. Six patients conceived, and ovarian volumes were greater and serum progesterone concentrations higher during conceptual cycles than during nonconceptual cycles.

Suspected ectopic pregnancy: ultrasound findings and hCG levels assessed by an immunofluorometric assay

One hundred suspected ectopic pregnancies were assessed by ultrasound on the basis of the following criteria: (A) viable intrauterine fetus, intrauterine pregnancy is certain; (B) intrauterine double sac or eccentric ring, intrauterine pregnancy is probable; (C) empty uterus or central ring but no adnexal mass or cul-de-sac fluid, ectopic pregnancy is possible; (D) empty uterus or central ring and an adnexal mass or cul-de-sac fluid, ectopic pregnancy is probable; (E) viable ectopic fetus, ectopic pregnancy is certain. Serum human chorionic gonadotrophin (S-hCG) was detected by an immunofluorometric assay (sensitivity 0.2 i.u./l, cut-off level 10 i.u./l). All the 51 patients in groups A and B had an intrauterine pregnancy. Normal gestational sacs were found also at S-hCG levels of less than 3600 i.u./l, the lowest level being 894 i.u./l. Ectopic pregnancy was confirmed in 29 of the 30 women in groups D and E. In the 19 women categorized into group C serial hCG assay and repeated sonography diagnosed ectopic pregnancy in 12 and miscarriage of an intrauterine pregnancy in the other seven. Ectopic pregnancy was always found when no gestational sac was seen by sonography and the hCG level was greater than 1000 i.u./l.