Background
Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven ...effective. Uterine artery embolization has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence that is based on case controlled studies and case reports. This is an update of the review previously published in 2012.
Objectives
To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.
Search methods
We searched sources including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries. The search was last conducted in April 2014. We contacted authors of eligible randomised controlled trials to request unpublished data.
Selection criteria
Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids. The primary outcomes of the review were patient satisfaction and live birth rate (among women seeking live birth).
Data collection and analysis
Two of the authors (AS and JKG) independently selected studies, assessed quality and extracted data. Evidence quality was assessed using GRADE methods.
Main results
Seven RCTs with 793 women were included in this review. Three trials compared UAE with abdominal hysterectomy, two trials compared UAE with myomectomy, and two trials compared UAE with either type of surgery (53 hysterectomies and 62 myomectomies).
With regard to patient satisfaction rates, our findings were consistent with satisfaction rates being up to 41% lower or up to 48% higher with UAE compared to surgery within 24 months of having the procedure (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.59 to 1.48, 6 trials, 640 women, I2 = 5%, moderate quality evidence). Findings were also inconclusive at five years of follow‐up (OR 0.90; 95% CI 0.45 to 1.80, 2 trials, 295 women, I2 = 0%, moderate quality evidence). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy, but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution (live birth: OR 0.26; 95% CI 0.08 to 0.84; pregnancy: OR 0.29; 95% CI 0.10 to 0.85, 1 study, 66 women).
Similarly, for several safety outcomes our findings showed evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups. This applied to intra‐procedural complications (OR 0.91; 95% CI 0.42 to 1.97, 4 trials, 452 women, I2 = 40%, low quality evidence), major complications within one year (OR 0.65; 95% CI 0.33 to 1.26, 5 trials, 611 women, I2 = 4%, moderate quality evidence) and major complications within five years (OR 0.56; CI 0.27 to 1.18, 2 trials, 268 women). However, the rate of minor complications within one year was higher in the UAE group (OR 1.99; CI 1.41 to 2.81, 6 trials, 735 women, I2 = 0%, moderate quality evidence) and two trials found a higher minor complication rate in the UAE group at up to five years (OR 2.93; CI 1.73 to 4.93, 2 trials, 268 women).
UAE was associated with a higher rate of further surgical interventions (re‐interventions within 2 years: OR 3.72; 95% CI 2.28 to 6.04, 6 trials, 732 women, I2 = 45%, moderate quality evidence; within 5 years: OR 5.79; 95% CI 2.65 to 12.65, 2 trials, 289 women, I2 = 65%). If we assumed that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE.
The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery (OR 0.07; 95% CI 0.01 to 0.52, 2 trials, 277 women, I2 = 0%). UAE was also associated with a shorter procedural time (two studies), shorter length of hospital stay (seven studies) and faster resumption of usual activities (six studies) in all studies that measured these outcomes; however, most of these data could not be pooled due to heterogeneity between the studies.
The quality of the evidence varied, and was very low for live birth, moderate for satisfaction ratings, and moderate for most safety outcomes. The main limitations in the evidence were serious imprecision due to wide confidence intervals, failure to clearly report methods, and lack of blinding for subjective outcomes.
Authors' conclusions
When we compared patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) our findings are that there is no evidence of a difference between the interventions. Findings at five year follow‐up were similarly inconclusive. There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE, but this information was only available from a selected subgroup in one small trial.
We found no clear evidence of a difference between UAE and surgery in the risk of major complications, but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. If we assume that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE. This increase in the surgical re‐intervention rate may balance out any initial cost advantage of UAE. Thus although UAE is a safe, minimally invasive alternative to surgery, patient selection and counselling are paramount due to the much higher risk of requiring further surgical intervention.
Background
Endometriomata are endometriotic deposits within the ovary. The surgical management of these blood filled cysts is controversial. The laparoscopic approach to the management of ...endometriomata is favoured over a laparotomy approach as it offers the advantage of a shorter hospital stay, faster patient recovery and decreased hospital costs. Currently the commonest procedures for the treatment of ovarian endometriomata are either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall.
Objectives
The objective of this review was to determine the most effective technique for treating an ovarian endometrioma, either excision of the cyst capsule or drainage and electrocoagulation of the cyst wall, measuring the outcomes improvement in pain symptoms and fertility. The primary endpoints assessed were the relief of pain and, in women desiring to conceive, the subsequent pregnancy rate (either spontaneous or as part of fertility treatment). Secondary outcomes assessed were the recurrence of the endometrioma and the recurrence of symptoms.
Search methods
The review authors searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials (to 31st August 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009) and reference lists of articles; and handsearched relevant journals and conference proceedings and contacted leaders in the field of endoscopic surgery throughout the world.The Cochrane Menstrual Disorders and Subfertility Group Specialised Register is based on regular searches of MEDLINE, EMBASE, CINHAL and CENTRAL.
Selection criteria
Randomised controlled trials of excision of the cyst capsule versus drainage and electrocoagulation of the cyst in the management of ovarian endometriomata.
Data collection and analysis
Review authors assessed eligibility and trial quality.
Main results
Two randomised studies of the laparoscopic management of ovarian endometriomata, size greater than 3 cm, for the primary symptom of pain were included. For the primary outcome measures laparoscopic excision of the cyst wall of the endometrioma was associated with a reduced recurrence rate of the symptoms of dysmenorrhoea (painful periods) (odds ratio (OR) 0.15, 95% CI 0.06 to 0.38), dyspareunia (OR 0.08, 95% CI 0.01 to 0.51) and non‐menstrual pelvic pain (OR 0.10, 95% CI 0.02 to 0.56). In those women subsequently attempting to conceive excision of the cyst wall was also associated with a subsequent increased spontaneous pregnancy rate in women who had documented prior subfertility (OR 5.21, 95% CI 2.04 to13.29) compared to women who underwent laparoscopic ablation of the endometrioma. For the secondary outcome measures laparoscopic excision of the cyst wall was associated with a reduced rate of recurrence of the endometrioma (OR 0.41, 95% CI 0.18 to 0.93) and with a reduced requirement for further surgery (OR 0.21, 95% CI 0.05 to 0.79) compared with surgery to ablate the endometrioma. A further randomised study was identified that demonstrated an increased ovarian follicular response to gonadotrophin stimulation for women who had undergone excisional surgery when compared to ablative surgery (mean difference (MD) 0.6, 95% CI 0.04 to1.16). There is insufficient evidence to support excisional surgery over ablative surgery with respect to the chances of pregnancy after controlled ovarian stimulation and intra‐uterine insemination (OR 1.40, 95% CI 0.47 to 4.15).
Authors' conclusions
There is good evidence that excisional surgery for endometriomata provides a more favourable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and subsequent spontaneous pregnancy in women who were previously subfertile. Consequently this approach should be the favoured surgical approach. However in women who may subsequently undergo fertility treatment, insufficient evidence exists to determine the favoured surgical approach.
To measure the accessibility of Australian web‐based health information for midlife women including those from culturally and linguistically diverse (CALD) backgrounds or with low health literacy.
...Search terms relating to midlife health were entered into Google Australia to identify health information websites. The content of the first two results pages was assessed using the European Commission's quality criteria for health websites. Readability was assessed using the Flesch Readability Ease Score with Grade 8 accepted as the average Australian reading level.
Sixteen websites were evaluated. Accessibility scores ranged between 0 and 8. The Victorian Government's health website Better Health Channel and the Jean Hailes for Women's Health website contained the most accessible information, each scoring 8, but were both ‘difficult to read’ on the readability test. Four websites included written resources in languages other than English and two had information in audio‐visual format in languages other than English.
There is a gap in accessible online health information for Australian women from CALD backgrounds or those with low health literacy.
Healthy behaviour changes in midlife may lead to better health in older age. More accessible health information resources are needed for women in midlife from CALD backgrounds and those with low health literacy.
No sweat: managing menopausal symptoms at work Hickey, Martha; Riach, Kathleen; Kachouie, Reza ...
Journal of psychosomatic obstetrics and gynaecology,
07/2017, Letnik:
38, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Introduction: Menopause usually occurs between the ages of 45 and 55, a time when women are likely to be in the paid workforce. Most women have menopausal symptoms and these may impact on daytime ...function and work performance. This study examines the relationship between reproductive stage, menopausal symptoms and work, and advises how employers can best support menopausal women.
Methods: An online and paper-based survey was completed in 2015-16 by 1092 women (22% response rate) aged 40 years plus employed in three hospitals in metropolitan Australia. Survey questions examined demographics, health and lifestyle variables, menopausal symptom reporting, and work-related variables. Reproductive stage was determined using modified STRAW +10 principal and descriptive criteria.
Results: Reproductive stage was not significantly associated with work engagement, organizational commitment, job satisfaction, work limitations and perceived supervisor support. Postmenopausal women had lower intention to leave their organizations than pre- and peri-menopausal women. While sleep problems were the most commonly reported menopausal symptom by peri-menopausal women, for postmenopausal women it was joint and muscular discomfort. Only hot flushes and vaginal dryness were significantly more frequent in peri- and post, compared to pre-menopausal women. In general, women rated their work performance as high and did not feel that menopausal symptoms impaired their work ability. Most women would appreciate greater organizational support, specifically temperature control, flexible work hours and information about menopause for employees and managers.
Discussion: Most women did not believe that menopausal symptoms negatively impacted on their work. Organizational changes may reduce the burden of menopausal symptoms in the workplace
Female gametes are stored in the ovary in structures called primordial follicles, the supply of which is non-renewable. It is well established that DNA-damaging cancer treatments can deplete the ...ovarian reserve of primordial follicles, causing premature ovarian failure and infertility. The precise mechanisms underlying this chemotherapy-driven follicle loss are unclear, and this has limited the development of targeted ovarian-protective agents. To address this fundamental knowledge gap, we used gene deletion mouse models to examine the role of the DNA damage-induced pro-apoptotic protein, PUMA, and its transcriptional activator TAp63, in primordial follicle depletion caused by treatment with cyclophosphamide or cisplatin. Cyclophosphamide caused almost complete destruction of the primordial follicle pool in adult wild-type (WT) mice, and a significant destructive effect was also observed for cisplatin. In striking contrast, Puma
mice retained 100% of their primordial follicles following either genotoxic treatment. Furthermore, elimination of PUMA alone completely preserved fertility in cyclophosphamide-treated mice, indicating that oocytes rescued from DNA damage-induced death can repair themselves sufficiently to support reproductive function and offspring health. Primordial follicles were also protected in TAp63
mice following cisplatin treatment, but not cyclophosphamide, suggesting mechanistic differences in the induction of apoptosis and depletion of the ovarian reserve in response to these different chemotherapies. These studies identify PUMA as a crucial effector of apoptosis responsible for depletion of primordial follicles following exposure to cyclophosphamide or cisplatin, and this indicates that inhibition of PUMA may be an effective ovarian-protective strategy during cancer treatment in women.
During the COVID-19 pandemic some Australians turned to artistic creative activities (ACAs) as a way of managing their own mental health and well-being. This study examined the role of ACAs in ...regulating emotion and supporting mental health and well-being during the COVID-19 pandemic, and also attempted to identify at-risk populations. We proposed that (1) participants would use ACAs as avoidance-based emotion regulation strategies; and (2) music engagement would be used for emotion regulation. Australian participants (
= 653) recruited from the general public completed an online survey, which included scales targeting anxiety (GAD7 scale), depression (PHQ9 scale) and loneliness (two UCLA Loneliness Scales, referring to "Before" and "Since" COVID-19). Participants reported which ACAs they had undertaken and ceased during the pandemic using an established list and ranked their undertaken ACAs in terms of effectiveness at making them "feel better." For their top-ranked ACA, participants then completed the Emotion Regulation Scale for Artistic Creative Activities (ERS-ACA), and if participants had undertaken any musical ACAs, also the Musical Engagement Questionnaire (MusEQ). The results supported both hypotheses. ANOVAs indicated that participants ranked significantly higher on the "avoidance" ERS-ACA subscale than the other subscales, and that participants ranked significantly higher on the emotion regulation and musical preference MusEQ subscales than the other subscales. Additionally, while ACAs such as "Watching films or TV shows" and "Cookery or baking" were common, they ranked poorly as effective methods of emotion regulation, whereas "Listening to music" was the second-most frequently undertaken ACA and also the most effective. "Singing" and "Dancing" were among the most ceased ACAs but also ranked among the most effective for emotion regulation, suggesting that support for developing pandemic-safe approaches to these ACAs may provide well-being benefits in future crises. Additionally, correlation analyses showed that younger participants, those who took less exercise during the pandemic, and those with the highest musical engagement reported the poorest well-being. We conclude that ACAs provided an important resource for supporting mental health and well-being during the COVID-19 pandemic in Australia and could potentially support mental health and well-being in future crises.
IMPORTANCE: There has been a worldwide secular trend toward earlier onset of puberty in the general population. However, it remains uncertain if these changes are paralleled with increased incidence ...of central precocious puberty (CPP) and normal variant puberty (ie, premature thelarche PT and premature adrenarche PA) because epidemiological evidence on the time trends in the incidence of these puberty disorders is scarce. OBJECTIVE: To provide valid epidemiological data on the 20-year secular trend in the incidence rates of CPP and normal variant puberty. DESIGN, SETTING, AND PARTICIPANTS: This population-based, 20-year cohort study used national registry data for all youth in Denmark registered with an incident diagnosis of CPP, PT, or PA in the Danish National Patient Registry from 1998 to 2017 (N = 8596) using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). We applied the maximum diagnostic age limit for precocious puberty (ie, onset of puberty before age 8 years for girls and age 9 years for boys) with and without a 12-month lag to address time from first contact to final registration in the Danish National Patient Registry. Data analysis was conducted in 2019. EXPOSURES: Diagnosis of CPP, PT, or PA. MAIN OUTCOMES AND MEASURES: The age-specific and sex-specific incidence rates of first-time diagnosis of CPP, PT, and PA were estimated using data from the Danish National Patient Registry from 1998 to 2017, and information about the total number of children at risk within the same age groups and sex from Statistics Denmark. Incidences were stratified according to immigration group (Danish origin, first-generation immigrant, second-generation immigrant). RESULTS: Overall a total 8596 children (7770 90.4% girls; median interquartile age at diagnosis for boys, 8.0 7.1-9.0 years; for girls, 8.0 7.6-8.5 years) were registered with an incident diagnosis of CPP, PT, or PA, of whom 7391 (86.0%) had Danish origin (6671 90.3% girls), corresponding to 370 new cases in children with Danish origin per year. The 20-year mean annual incidence rates of CPP, PT, PA, and all 3 conditions per 10 000 girls with Danish origin were 9.2 (95% CI, 8.0 to 10.3), 1.1 (95% CI, 0.7 to 1.5), 1.3 (95% CI, 0.9 to 1.7), and 11.5 (95% CI, 10.3 to 12.8), respectively. For boys with Danish origin, the 20-year mean annual incidence rates per 10 000 boys were lower: 0.9 (95% CI, 0.6 to 1.2), 0.2 (95% CI, 0.1 to 0.4), and 1.1 (95% CI, 0.7 to 1.4) for CPP, PA, and the sum, respectively. There was a 6-fold increase in incidence for girls with Danish origin (from 2.6 per 10 000 to 14.6 per 10 000) and a 15-fold increase for boys with Danish origin (from 0.1 per 10 000 to 2.1 per 10 000). The 20-year mean incidence of CPP and PA among girls in the first-generation and second-generation immigrant groups were greater than that of girls with Danish origin. The incidence rate for CPP per 10 000 girls in the first-generation and second-generation groups were 13.7 (95% CI, 9.3 to 18.2) and 14.2 (95% CI, 4.6 to 23.9), respectively; the incidence rate for PA per 10 000 girls in the first-generation and second-generation groups were 2.0 (95% CI, 0.3 to 3.6) and 1.5 (95% CI, −1.6 to 4.7), respectively. No differences associated with immigration status were observed among boys. CONCLUSIONS AND RELEVANCE: Our findings suggest that the annual incidence of CPP and normal variant puberty has substantially increased in Denmark during the last 20 years. These findings have implications for short-term and long-term health and potentially for the international classification of the reference age of puberty.
For many young women with early breast cancer, fertility is a priority. Interventions to retain fertility options generally need to be accessed before chemotherapy, but many women do not receive ...information regarding these options in a timely fashion. Knowledge about fertility and decisional conflict has not previously been measured in young patients with breast cancer considering future pregnancies.
One hundred eleven young women with early breast cancer who had not yet completed their families were recruited around the time of diagnosis. Knowledge regarding fertility-related information, decisional conflict, and preferences regarding fertility information and decision making was measured.
From a potential fertility-related knowledge score of 10, the mean was 5.2 (standard deviation = 2.3; range, 0 to 10). Decreased knowledge was associated with increased decisional conflict about pursuing fertility preserving interventions (odds ratio OR = 0.57; 95% CI, 0.44 to 0.73; P < .001). Thirty-one percent of women reported that they would consider undertaking in vitro fertilization (IVF) as a method to conserve their fertility, whereas 38% were uncertain. Consideration of IVF was not related to whether subjects were in a committed relationship (OR = 1.20; P = .716) or a definite desire for more children (OR = 1.54; P = .513).
Around diagnosis, many young patients with breast cancer have low levels of knowledge about fertility issues. Further, low knowledge is associated with increased decisional conflict, which is likely to undermine the quality of decision making. These findings suggest that targeted and timely fertility information may reduce decisional conflict and increase informed choice. Neither relationship status nor firm plans regarding future children reliably predict desire to pursue fertility preservation.
Polycystic ovary syndrome (PCOS) is challenging to diagnose. While the 2003 Rotterdam criteria are widely used for adults, the 2018 international PCOS guideline recommended updated Rotterdam criteria ...with both hyperandrogenism and oligo-anovulation for adolescents based on evidence-informed expert consensus. This study compared the prevalence of PCOS using updated and original Rotterdam criteria in community-based adolescents and explored long-term body mass index (BMI) trajectories across different diagnostic phenotypes.
Overall, 227 postmenarchal adolescent females from the prospective cohort Raine Study undertook comprehensive PCOS assessment at age 14-16 years. Detailed anthropometric measurements were collected from birth until age 22 years. Cross-sectional and longitudinal BMI were analyzed using t tests and generalized estimating equations.
PCOS was diagnosed in 66 (29.1%) participants using original criteria versus 37 (16.3%) participants using updated Rotterdam criteria. Using updated criteria, participants with PCOS had higher BMI than participants without PCOS from prepubertal. Only the phenotype meeting the updated criteria was significantly associated with higher long-term BMI gain whereas other PCOS phenotypes had similar BMI trajectories to participants without PCOS (p < 0.001).
The use of the 2018 updated Rotterdam criteria reduces over-diagnosis of PCOS in adolescents and identifies those at the greatest risk of long-term weight gain, a key contributor to disease severity and long-term health implications. The BMI trajectories of females with PCOS on updated criteria diverge prepubertally compared to those without PCOS. This work supports targeting adolescents diagnosed with PCOS on the 2018 updated criteria for early lifestyle interventions to prevent long-term health complications.
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