Professional Documents
Culture Documents
Controversies Gynecology
Controversies Gynecology
Gynecology
Dr. Mohammed Abdalla
Egypt, Domiat G. Hospital
serious
disagreements
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1
Screening for Ovarian Cancer..Yes
Or No ?
Pelvic Examination
is of unknown sensitivity in detecting ovarian
cancer.
Ovarian cancers detected by pelvic examination
are generally advanced
Tumor markers
Carcinoembryonic antigen, ovarian cystadenocarcinoma
antigen CA125
The reported sensitivities of CA-125 in detecting stage I and
stage II cancers are 29- 75% and 67-100%, respectively
Tumor markers may have limited specificity. It has been
reported that CA- 125 is elevated in 1% of healthy women,
6-40% of women with benign masses it may be possible to
improve the specificity of CA-125 measurement by
selective screening of postmenopausal women
Ultrasound imaging
detect masses as small as 1 cm, and distinguish
solid lesions from cysts. Transvaginal colorflow Doppler ultrasound can also identify
vascular patterns associated with tumors.
sensitivity50-100%
specificity76-97%,
Key Recommendations
There are no official recommendations to
screen routinely for ovarian cancer in
asymptomatic women by performing
ultrasound or serum tumor marker
measurements
Key Recommendations
A national institutes of health consensus
conference on ovarian cancer recommended
taking a careful family history and
performing an annual pelvic examination on
all women
Key Recommendations
American college of obstetricians and
gynecologists the pelvic examination (and
pap smear) is recommended annually for all
women who are or have been sexually
active
Key Recommendations
The NIH consensus conference concluded that
women with presumed hereditary cancer
syndrome should undergo annual pelvic
examinations, CA-125 measurements, and
transvaginal ultrasound until childbearing is
completed or at age 35, at which time
prophylactic bilateral oopherectomy was
recommended
Routine Screening
for Ovarian
Cancer Cannot Be
Recommended.
2
Endometrial Resection and
.. Ablation Versus Hysterectomy
Endometrial sampling has excluded cancer, precancer, or structural abnormalities (polyps, fibroids)
that require surgery. And
The total coast of endometrial destruction was significantly lower than the
cost of hysterectomy but the difference between the two procedures narrowed
over time because of the high cost of re-treatment in the endometrial destruction
group.
Ablation
yes
Although a subsequent
hysterectomy rate of 20% after
endometrial ablation may seem
high, 80% of women who
otherwise would have had a
hysterectomy will avoid it with
an endometrial ablation. *
ablation technology is becoming
less expensive, more user
friendly,
requires
less
anesthesia and analgesia, and
is producing about 85% patient
satisfaction.
No
Hysterectomy remains a skilldependent procedure with 100%
effectiveness. However, its safety
record for death and injury
compares unfavorably with
ablation. Its costs are higher and
recovery is longer. The long term
problems with ablation are failure
before menopause requiring a
repeat procedure, and the
unknown rate of post ablation
endometrial cancer.
Cochrane Reviewers'
Conclusions
Endometrial destruction offers an alternative to
hysterectomy as a surgical treatment for heavy
menstrual bleeding. Both procedures are effective
and satisfaction rates are high. Although
hysterectomy is associated with a longer operating
time, a longer recovery period and higher rates of
post-operative complications, it offers permanent
relief from heavy menstrual bleeding. The cost of
endometrial destruction is significantly lower than
hysterectomy but since re-treatment is often
necessary the cost difference narrows
ISSUE 1, 2003
3
Pre-operative endometrial thinning agents
before hysteroscopic surgery ?
Cochrane Reviewers'
Conclusions
Endometrial thinning prior to hysteroscopic surgery for
menorrhagia improves both the operating conditions for
the surgeon and short term post-operative outcome.
Gonadotrophin-releasing hormone analogues produce
slightly more consistent endometrial thinning than
danazol, though both agents produce satisfactory results.
The effect of these agents on longer term post-operative
outcomes and the need for further surgical intervention
has not been considered in the studies included in this
review.
ISSUE 1. 2003
4
Managing Patients With Large
Symptomatic Fibroids
UAE) Vs myomectomy)
3.
4.
Lee PI, Yoon JB, Joo KY. Uterine artery ligation for symptomatic
leiomyomas. The Journal of the American Association of Gynecologic
Laparoscopists. 2000;7(suppl):S32.
Park KH, Kim JY, Chung JE. New treatment of myomas: angioblock and
uterine artery ligation. The Journal of the American Association of
Gynecologic Laparoscopists. 2000;7(suppl):S46.
5
Interventions for Tubal Ectopic
Pregnancy..Which Approach and
?When
Local methotrexate
is not a treatment option. Injection of this drug, both under
laparoscopic guidance and under ultrasound guidance, is significantly
less successful in the elimination of tubal pregnancy.
Systemic methotrexate
Multiple dose
associated with a greater
impairment of health related
quality of life compared with
laparoscopic salpingostomy
Single dose
is not effective enough in eliminating the
tubal
pregnancy
compared
to
laparoscopic salpingostomy. This as a
result of inadequately declining serum
hCG concentrations after one single dose
of methotrexate necessitating additional
methotrexate injections or surgical
interventions.
Cochrane Reviewers'
Conclusions
Laparoscopic surgery is the cornerstone of treatment in the
majority of women with tubal pregnancy. If the diagnosis of
tubal pregnancy can be made noninvasively, medical
treatment with systemic methotrexate in a multiple dose
intramuscular regimen is an alternative treatment option but
only in hemodynamically stable women with an unruptured
tubal pregnancy and no signs of active bleeding presenting
with low initial serum hCG concentrations, after properly
informing them about the risks and benefits of the available
treatment options.
Citation: Hajenius PJ, mol BWJ, Bossuyt PMM, Ankum WM,
van der Veen F. Interventions for tubal ectopic
pregnancy (Cochrane review). In: the Cochrane library,
issue 1 2003. Oxford: update software.
6
Evaluation of abnormal uterine bleeding
Office hysteroscopy vs saline infusion Sonography
(SIS)
Key Recommendation
SIS made by skilled operators allows an accurate
evaluation of uterine cavity and malformations,
particularly in young women, reaching a diagnostic
accuracy similar to that of hysteroscopy, improving
the examination compliance and lowering both risks
and side effects.
F.M. Severi, C. Bocchi, P. Florio, L. Cobellis, R. La Rosa, M.G. Ricci and F.
Petraglia Chair of Obstetrics and Gynecology, University of Siena, Siena, Italy
7
Therapeutic Conization .Is There a
Necessity of Removing the Entire
endocervical canal in all cases
By performing endocervical
curettage or by obtaining cytology
with an endocervical brush. If these
tests are negative for CIN or
glandular atypia, and if the patient
wishes to preserve her childbearing
potential, we preserve the cranial
extremity of the endocervical canal.
8
Clomiphene citrate for unexplained
subfertility in women
9
Metformin as a treatment option in
.PCO patients