General Gynecology Clinic Research Articles

EP31.08: Does hormonal status influence uterine venous diameter?

Pelvic venous congestion (PVC) primarily affects premenopausal (Pre-M) women and is characterised by evidence of pelvic varicosities on transvaginal ultrasound (TVS). Postmenopausal (Po-M) women rarely exhibit these symptoms suggesting that hormonal influence is a definite factor. The aim of this study was to examine the affect hormonal status has on vein diameter. This was a single-centre, prospective cross-sectional study of women attending our general gynecology clinic during a 16-month period. Demographic data and a full medical/surgical history were recorded. Exclusion criteria included age<18 years, previous hysterectomy, contraindication to/declining TVS and evidence of pelvic pathology on TVS. All women underwent TVS assessment of the pelvic organs and pelvic veins. The Mann Whitney U-test was used to compare the diameters between Pre-M and Po-M women. Linear regression was performed to examine whether exogenous hormone use influenced venous diameter. 486 women had normal pelvic organs out of 1500 women examined. Of these, 375 were Pre-M and 111 were Po-M. Overall, the pelvic vessel diameters were smaller in Po-M women, with statistical significance observed in the right vein and both sides combined. Exogenous hormone use in the Pre-M group was associated with smaller vessel diameters, with statistical significance in the left vein (p = 0.001). There was no association between vein diameter and HRT use in the Po-M group (p = 0.98 left vein; p = 0.64 right vein). Our findings showed that Pre-M women have larger pelvic veins than Po-M women. These findings provide further insight into the biomechanics of veins and hence suggest that they are sensitive to hormonal fluctuations. This is further supported by our findings revealing that suppression of ovarian activity with hormones in Pre-M women leads to a reduction in vein diameter, which is often treatment for PVC. EP31.08: Table 1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Category – Imaging

Introduction Ultrasound is considered as the first‐line imaging method of choice in gynaecology due to it being a simple, accurate, and safe technique. The quality and diagnostic accuracy of ultrasound depends on the skills of the individual performing the ultrasound scan. Despite the implications that poor ultrasound practice has on patient safety, the role of training and evaluation of ultrasound practice has received limited attention. Aim Ultrasound practice in a general gynaecology clinic was assessed by evaluating the video‐recorded quality of ultrasound images and comparing these to best practice guidelines; Objective Structured Assessment of Ultrasound Skills (OSAUS), Society and College of Radiographers, British Medical Ultrasound Society (SCoR/BMUS), and International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG). Methods A video recording device was connected to a randomly selected ultrasound machine in gynaecology clinics of a busy teaching hospital. To minimise the Hawthorne effect, staff were notified through email 3 weeks in advance. Data were collected over a three‐week period. The anonymised recordings were analysed against current best practice guidelines. Ultrasound practice was categorised as compliant, partially compliant and noncompliant. Results In total, 43 observations of ultrasound use were recorded and findings with regard to the three categories were recorded as percentage frequencies (%). The study found 41.9% of images were annotated appropriately and 25.6% of clinicians examined bladder, vagina, and cervix when indicated. Assessment of image optimisation was compliant in 23.3% of recorded observations, 11.6% partially compliant, and 65.1% noncompliant. The study also found that the global examination on gynaecology was 20.9% compliant, 18.6% partially compliant, and 60.47% noncompliant. Conclusion The study has shown that ultrasound practice among gynaecologists did not reflect the standards of current guidelines. The results suggest a need for improvement, through supervised training and core knobology. Accuracy and performance of ultrasound examination remains highly operator‐dependent. Video surveillance of ultrasound use was found to be an effective tool for assessing competence and performance of ultrasound examination.

Morphometry of the nulliparous pelvic floor.

To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its association with characteristics such as age and body mass index (BMI). This was a prospective study performed between January 2013 and November 2015 in non-pregnant nulliparous women attending a general gynecology clinic. Following collection of demographic data, women were examined using translabial four-dimensional (4D) ultrasound. Dynamic volumes of pelvic floor muscle were obtained at rest, on maximal contraction and on Valsalva maneuver, and analyzed at a later date by an assessor blinded to demographic details. Standard measurements for each volume included levator hiatal area and anteroposterior and transverse diameters, and pubovisceral muscle length and width. Subanalysis was performed comparing women with and those without pelvic pain. Linear regression analysis was performed to assess the association between characteristics, including age and BMI, and levator hiatal area at rest. Three hundred and sixty eight nulliparous women were examined using translabial 4D ultrasound. Median levator hiatal area was 10.62 cm2 at rest, 11.95 cm2 on Valsalva maneuver and 8.18 cm2 on maximal contraction. There was no difference between women with and those without pelvic pain when comparing biometric measurements of the pelvic floor musculature, except for in pubovisceral muscle width during the contraction phase. Regression analysis demonstrated that higher age and BMI were associated with increased levator hiatal area measurement. Pelvic floor morphometry in nulliparous women is unchanged by pelvic pain, but levator hiatal area is increased in women with higher BMI and age. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Sexually Transmitted Infections Detected by Multiplex Real Time PCR in Asymptomatic Women and Association with Cervical Intraepithelial Neoplasia.

To determine the frequency of sexually transmitted infections (STIs) in asymptomatic women and the association of STIs with cervical intraepithelial neoplasia (CIN). A cross-sectional study was performed, enrolling women examined in a general gynecology clinic and in a colposcopy referral center from October 2014 to October 2015. The colposcopy group consisted of 71 women, and the general gynecology group consisted of 55 women. Cervical samples were collected for cervical cytology and a multiplex real-time polymerase chain reaction (PCR) was developed to detect human papillomavirus (HPV) and the STIs caused by the following microorganisms: Chlamydia trachomatis, Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma urealyticum, and Neisseria gonorrhoeae. A multivariate analysis was performed by logistic regression, considering the significance level of 0.05. The general frequency of STIs was: 46.8% (HPV); 27.8% (C. trachomatis); 28.6% (M. genitalium); 0.8% (M. hominis); 4.8% (U. urealyticum); and 4.8% (N. gonorrhoeae). The significant risk factors for CIN were: HPV infection (odds ratio [OR] = 2.53; p = 0.024); C. trachomatis (OR = 3.04; p = 0.009); M. genitalium (OR = 2.37; p = 0.04); and HPV and C. trachomatis coinfection (OR = 3.11; p = 0.023). After the multivariate analysis, a significant association was found between HPV and CIN (OR = 2.48; 95% confidence interval [95%CI]: 1.04-5.92; p = 0.04); and between C. trachomatis and CIN (OR = 2.69; 95%CI: 1.11-6.53; p = 0.028). The frequency of STIs was high in asymptomatic patients. Infections by HPV and C. trachomatis were independently associated with the presence of CIN. The high frequency of STIs in asymptomatic women suggests the need for routine screening of these infections.

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.

Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic. One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124. A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10-28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038). POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.

Urinary Metabolic Phenotyping of Women with Lower Urinary Tract Symptoms.

Lower urinary tract symptoms (LUTS), including urinary incontinence, urgency and nocturia, affect approximately half of women worldwide. Current diagnostic methods for LUTS are invasive and costly, while available treatments are limited by side effects leading to poor patient compliance. In this study, we aimed to identify urine metabolic signatures associated with LUTS using proton nuclear magnetic resonance (1H NMR) spectroscopy. A total of 214 urine samples were collected from women attending tertiary urogynecology clinics (cases; n = 176) and healthy control women attending general gynecology clinics (n = 36). Despite high variation in the urine metabolome across the cohort, associations between urine metabolic profiles and BMI, parity, overactive bladder syndrome, frequency, straining, and bladder storage were identified using KODAMA (knowledge discovery by accuracy maximization). Four distinct urinary metabotypes were identified, one of which was associated with increased urinary frequency and low BMI. Urine from these patients was characterized by increased levels of isoleucine and decreased levels of hippurate. Our study suggests that metabolic profiling of urine samples from LUTS patients offers the potential to identify differences in underlying etiology, which may permit stratification of patient populations and the design of more personalized treatment strategies.

Talk About Sex: Sexual History-Taking Preferences Among Urogynecology Patients and General Gynecology Controls.

The aim of the study was to investigate patients' experiences and preferences regarding sexual history taking. We also sought to compare preferences between women in general gynecology versus urogynecology clinics and between women of different ages. This is a survey of 219 patients presenting in gynecology and 164 in urogynecology clinics. Surveys were voluntary and anonymous. Survey instruments included questions about sexual function, past experiences, and preferences regarding taking a clinical sexual history. Subjects agreed that sexual health is important for overall health and should be asked about regularly. Most respondents were not embarrassed to discuss sexual history. When asked about experience with providers, subjects reported that their primary care providers (PCPs) inquired infrequently about their sexual health. Respondents perceived that obstetrician-gynecologists asked about sexual health more frequently than PCPs. There were no significant differences between general gynecology and urogynecology patients' history-taking preferences. Younger women were more likely to feel that sexual health was an important aspect of overall well-being, whereas older women were more likely to agree that sexual problems are unavoidable with age. On logistic regression, there was an association between the ages of younger than 40 years and expressing agreement that providers should frequently ask patients about sexual health. Agreeing that sexual health is an important part of well-being was also associated with being in the 40 years or younger group. Patients place importance on sexual health history as part of their overall health, and providers should more frequently query their patients about this topic. Both PCPs and obstetrician-gynecologists have room for improvement.

Prevalence of Domestic Violence in Hong Kong Chinese Women Presenting with Urinary Symptoms.

ObjectivesTo determine the prevalence of domestic violence and its risk factors in women presenting with urinary symptoms.MethodsThe study was carried out in the urogynecology clinic and general gynecology clinic, Department of Obstetrics and Gynecology, Queen Mary Hospital, Hong Kong from 1st May 2013 till 31st October 2014. Two hundred and twenty-five women presenting to the urogynecology clinic with urinary symptoms were categorized according to their symptoms and were asked to complete the Modified Abuse Assessment Screen. Demographic data of the subjects and their partners were collected. Mann-Whitney U test were used for analysis of continuous variables, while Chi-square test and Fisher Exact test were used for analysis of categorical variables between the abused and non-abused group. Prevalence of domestic violence were calculated and compared.ResultsThe prevalence of domestic violence among this group of patients (7.6%) was found to be lower when compared with other studies. Verbal abuse was the commonest form of violence in our locality. The median age of the abused group and the non-abused group were both 56 years old, with the age ranging from 40 to 64 and 29 to 70 years old respectively. The prevalence of domestic violence among patients with overactive bladder syndrome, stress urinary incontinence and mixed urinary incontinence were 19.5%, 4.2% and 5.5% respectively (Fisher Exact test for whole group, P<0.05).ConclusionThe prevalence and nature of abuse in our locality was different from the quoted figures worldwide. Patients with overactive bladder syndrome were more likely to be victims of abuse than patients with other urinary symptoms. The difference in the prevalence of domestic violence among patients with different urinary symptoms could be related to their underlying pathophysiology. When encountering patients with overactive bladder syndrome, clinicians should consider this high incidence of domestic violence and provide prompt referral whenever necessary.

Association between ultrasound features of adenomyosis and severity of menstrual pain.

To investigate the association between the ultrasound features of adenomyosis and the severity of menstrual pain. This was a prospective observational study set in the general gynecology clinic of a university teaching hospital between January 2009 and January 2010. A total of 718 consecutive premenopausal women aged between 17 and 55 years attended the clinic and underwent structured clinical and transvaginal ultrasound examinations in accordance with the study protocol. Morphological features of adenomyosis on ultrasound scan were recorded systematically. A quantitative assessment of menstrual pain was made by completion of a numerical rating scale (NRS). One hundred and fifty-seven (21.9% (95% CI, 18.8-24.9%)) women were diagnosed with adenomyosis on ultrasound. Multiple linear regression analysis showed that an ultrasound diagnosis of adenomyosis and ultrasound and laparoscopic diagnoses of endometriosis were significantly associated with menstrual pain when measured by an NRS. In addition, there was a statistically significant positive correlation between the severity of menstrual pain and the number of ultrasound features of adenomyosis seen. Women with ultrasound features of adenomyosis have more severe menstrual pain than do women without these features. The positive correlation between the number of ultrasound features of adenomyosis and the severity of menstrual pain could form the basis of a clinically relevant grading system for adenomyosis. A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be evaluated prospectively in different populations. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Polycystic ovarian syndrome: Analysis of management outcomes among infertile women at a public health institution in nigeria

Background: Infertility remains an issue of concern especially to the female partner who bears the brunt of the stigma attributed to the disease in this environment. Among the identified etiological factors for infertility, polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women of reproductive age that impact on ovulation and conception. Aims and Objectives: The objective of this study was to determine pregnancy outcome following the various modalities of management of PCOS at the University of Ilorin Teaching Hospital (UITH). Materials and Methods: This is a nonrandomized (nonblinded) clinical trial of five therapeutic options for infertile women with PCOS from the Assisted Reproductive Technology (ART) Clinic and Gynaecology Clinic of UITH between January 1, 2011 and December 31, 2013. Results: Of 624 infertile women who presented at ART and general gynecology clinic of UITH, 76 met the Rotterdam criteria for PCOS, giving a prevalence rate of 12.2%. The patients aged 20–44 years with a mean age of 31.5 years. Most 49 (64.5%) of the patients were nulliparous, and more than half (56.6%) belong to the middle social class. Thirty-four (44.8%) were obese while 22 (28.9%) were overweight. Of the various management options, 48.7% had laparoscopic ovarian drilling; other treatment options offered were the use of clomiphene citrate (CC) alone, CC with metformin, weight reduction, and gonadotropin. Patients were followed-up within 6–12 months (mean 5.5 ± 1.2 months) following the initial treatment for evidence of laboratory/clinical pregnancy. An overall pregnancy rate of 46.0% was recorded. However, a total of 13 (17.1%) were lost to follow-up. The highest pregnancy rate (75%) was reported in women managed with CC alone (P = 0.229). Conclusion: PCOS occurs commonly in reproductive age and management outcomes are promising in Nigeria. CC, metformin, and laparoscopic ovarian drilling are of great benefit. Further studies on PCOS in low resource countries are needed.

Lidocaine–prilocaine cream as analgesia for hysterosalpingography: a randomized, double blinded, controlled study

ObjectiveThe efficacy of lidocaine–prilocaine cream (EMLA®) analgesia in the practice of hysterosalpingography is controversial. This study provides new drill results and a new method of application in terms of mode, time and place. The aim of the paper is to investigate the efficacy of 5% lidocaine 25mg–prilocaine 25mg/g cream applied to the uterine cervix for reducing pain during hysterosalpingography. Study designA randomized, double blinded, controlled study set in the general gynaecology clinic of a university teaching hospital between September 2012 and June 2013. One hundred successive patients programmed to undergo hysterosalpingography were randomized to either 3ml of EMLA (50) cream or 3ml of placebo (50), placed endocervically and exocervically, 10min before hysterosalpingography. Patients’ intensity of pain was assessed in four steps: at baseline (speculum application), after application of Pozzi tenaculum and cannula on the uterine cervix, during cervical traction and after contrast medium injection, using a 10-cm Visual Analogue Scale (VAS) immediately after the procedure. The most painful step was also identified. VAS was administered again at one-month follow-up visit. Trial registration: NCT01303614. ResultsThe contrast medium injection was the most painful step of hysterosalpingography in both groups (EMLA 3.96, placebo 4.54, 95%CI: −0.481 to 1.641). No differences were found between the two groups (P=0.281) during this step. When comparing the VAS scale after the application of Pozzi tenaculum and cannula (EMLA 1.06, placebo 3.34, 95%CI: 1.495–3.065) and after cervical traction (EMLA 2.54, placebo 3.46, 95%CI: 0.034–1.806), significantly less pain was experienced by the EMLA group than the placebo group: P=0.000 and P=0.042, respectively. ConclusionEndocervical and exocervical topical application of EMLA 10min before performing hysterosalpingography significantly reduced pain during cervical manipulation with tenaculum and cannula and during cervical traction, but did not reduce pain during injection of contrast that was the most painful step.

Incidence and predictive factors for complications after uterine leiomyoma embolization.

What is the risk of complications after uterine leiomyoma embolization and what are the factors associated with complications? The cumulative risk of complications after embolization is relatively low even in the long term, but submucosal leiomyoma location may increase the risk. A broad spectrum of complications after leiomyoma embolization have been described with widely varying rates. There is uncertainty over the actual risk of complications and the factors associated with this risk. This was a prospective cohort study of 288 consecutive women undergoing leiomyoma embolization in the general gynaecology clinic of a university teaching hospital between January 2001 and December 2010. Complications occurring after embolization were categorized as major or minor according to the severity of their impact on health, the level of care required and the outcome. Cumulative complication rates were estimated by survival analysis and log-rank tests according to baseline variables. Multivariable Cox proportional hazards analysis was performed to adjust for confounders. There were 48 patients who experienced a complication at a median of 5 months (95% confidence interval, 4.1-11.4) after embolization. Complications were minor in 38 patients and major in 10 patients. The cumulative overall complication rate was 13% (95% CI, 9.0-17.0) at 6 months, 16% (95% CI, 11.0-20.0) at 1 year, 17% (95% CI, 12.0-22.0) at 3 years and 18% (95% CI, 12.9-22.8) at 5 years. The most frequent complication (19/48, 39.6%) was leiomyoma expulsion, which occurred spontaneously in 13 (68.4%) of these cases and required assistance in 6 (31.6%) cases. Eight (2.8%) patients underwent re-intervention, including six hysteroscopic myomectomies, one laparoscopic myomectomy and one hysteroscopic adhesiolysis, as a result of a complication. Submucosal leiomyoma location was the only baseline variable associated with an increased risk for complications [Hazard ratio (HR), 2.28, 95% CI, 1.24-4.18, P = 0.008]. Our population did not include women of African descent, who have been reported to be at higher risk of post-procedural complications compared with Causcasian women. If such women were involved in the study, higher morbidity rates might have been observed. Women with submucosal leiomyomas at the time of embolization are more likely to have post-procedural complications. This is important new information for counselling patients contemplating this therapeutic approach. The authors have no competing interests to declare. The study was not supported by any external grant.

Associations between individual lower urinary tract symptoms and bacteriuria in random urine samples in women

Previous studies have noted an association between a diagnosis of overactive bladder and bacteriuria, but little is understood about the relationship of bacteriuria to specific LUTS. We hypothesized that bacteriuria in women would be associated with increased self-reported symptom scores for a wide range of LUTS. Women were recruited from general gynecology and urogynecology outpatient clinics in a secondary care setting. Women completed the 12-item International Consultation on Incontinence Questionnaire for Female Lower Urinary Tract Symptoms and provided a clean-catch mid-stream specimen of urine for microscopy and culture. Women with acute urinary tract infection were excluded. Three statistical approaches (Mann-Whitney U-test, multivariable logistic regression, and receiver operating characteristic curves) were used to assess differences in symptom scores between women with and without bacteriuria. Two hundred forty-seven women were recruited, aged 22-82. Sixteen of 247 urine samples (6.5%) demonstrated significant bacteriuria, growing a different range of organisms. Women with significant bacteriuria were more likely to have nocturia (OR 3.56, 95% CI 1.19-10.6, P = 0.02), urgency (OR 6.66, 95% CI 1.47-30.06, P = 0.01), bladder pain (OR 2.82, 95% CI 1-7.92, P = 0.049), urgency incontinence (OR 2.92, 95% CI 1.02-8.36, P = 0.046), nocturnal enuresis (OR 4.21, 95% CI 1.32-13.41, P = 0.01). After adjustment for age, parity, symptomatic prolapse, menopausal status and history of mid-urethral sling urinary urgency, bladder pain, nocturia, and nocturnal enuresis remained significantly associated. Bacteriuria is associated with a range of LUTS including nocturia, urgency, and bladder pain supporting a role for bacterial colonization in the pathogenesis of OAB symptoms.

Is adenomyosis associated with menorrhagia?

Is the presence of adenomyosis associated with menorrhagia? There was no significant association between adenomyosis and menorrhagia, but there was a significant positive correlation between the severity of adenomyosis on ultrasound and the amount of menstrual loss estimated using pictorial blood loss assessment charts. There is no consensus in the literature with regards to the association between adenomyosis and menorrhagia. Previous studies have been limited to retrospective studies of highly selected populations which mainly included women who underwent hysterectomy. There are no large prospective studies evaluating the association between adenomyosis and menorrhagia, either in the general population of women or in a general gynaecology clinic setting. This was a prospective observational study set in the general gynaecology clinic of a university teaching hospital between January 2009 and January 2010. There were 714 consecutive premenopausal women who attended the clinic and underwent structured clinical and transvaginal ultrasound examination in accordance with the study protocol. Morphological features of adenomyosis were systematically recorded on ultrasound scan. Menorrhagia was determined subjectively by direct questioning and objectively by completion of pictorial blood loss analysis charts. A diagnosis of adenomyosis was made in 157/714 women [22.0% (95% CI: 19.1-25.2%)]. Multivariable analysis showed significant associations between submucous fibroids [OR 5.60 (95% CI: 2.69-11.6)], any fibroids [OR 1.53 (95% CI: 0.91-2.58)] and endometrial polyps [OR 2.81 (95% CI: 1.15-11.7)] and menorrhagia. There were also significant associations between increasing gravidity and BMI and menorrhagia (P < 0.01). There was no significant association between adenomyosis and menorrhagia in the study population, when adenomyosis was assessed as a binary outcome. When severity of adenomyosis was assessed by counting the number of morphological features of adenomyosis in each woman, we found a significant 22% increase in menstrual loss for each additional feature of adenomyosis [OR 1.21 (95% CI: 1.04-1.40)]. A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be prospectively evaluated in different populations. A better understanding of the relationship between adenomyosis and menorrhagia can help improve counselling of women regarding the significance of this common condition and facilitate future studies assessing the effectiveness of different conservative treatments protocols. The authors have no competing interests. The study was not supported by an external grant.

Dysmenorrhea: a study of affected factors and approaches to relief among female students at a college in southern Taiwan

Dysmenorrhea is a major problem in the general gynecology clinic. It causes discomfort among healthcare staffs and significant losses in terms of time and finances. The purpose of this study was to determine the affected factors of dysmenorrhea and evaluate the self-perceived efficacy of relief methods. A cross-sectional research design was used to collect data. Participants included 586 female students enrolled at a college in southern Taiwan. Data was analyzed using a t-test, one-way ANOVA, and Scheffe test. Traditional Chinese medicine pattern identifications related significantly to dysmenorrhea frequency perception. Lifestyle characteristics related significantly to dysmenorrhea level perception. Using shenghua decoction, siwu and pig blood decoction, Angelica drink, ginger, ziziphus jujube, brown sugar tea, and analgesics all related significantly to dysmenorrhea relief efficacy. Strategies found to help relieve dysmenorrhea level perception include increasing the duration and regularity of sleep and avoiding the consumption of pungent foods. Seeking and adhering to physician recommendations can also increase dysmenorrhea self-care efficacy. Dysmenorrhea-relief courses should be improved in hospitals and schools to assist women to self-manage dysmenorrhea more effectively.

Human Papillomavirus Infection in Women in Puerto Rico

This study aimed to describe the prevalence and concordance between cervical and anal human papillomavirus (HPV) infection and compare cervicovaginal and anal self-collection methods for HPV testing between physician and self-collected specimens in women in Puerto Rico. Specimens for HPV-DNA testing were obtained from 100 women aged 18 to 34 years attending a general gynecology clinic for a routine Pap smear. Human papillomavirus testing was performed using polymerase chain reaction MY09/MY11 primers. Positive samples were typed for 39 genotypes. Agreement between sampling methods was determined by percent agreement and the κ statistic. For the 39 genotypes evaluated, 38.4% (38/99) of cervicovaginal and 33.7% (30/89) of anal physician-collected samples were HPV+, whereas 35.1% (34/97) of cervicovaginal and 32.0% (31/97) of anal self-collected samples were positive. Human papillomavirus type 16 was the most common type identified in the cervix (8.3%, 8/97) and the anus (5.6%, 5/89) of physician-collected samples, with similar prevalence in self-collected samples. Concordance between cervical and anal HPV infection was high (>90%) for all types evaluated. There was a strong percent agreement between physician- and self-collected cervicovaginal and anal samples (>95% for all HPV types) and good to excellent agreement (κ > 0.60) for most HPV types. The clinic-based prevalence of anal and cervicovaginal HPV infection was high, with a strong concordance between cervical and anal infection and good to excellent agreement between physician- and self-collected samples. This study supports the feasibility of using cervical and anal self-sampling methods in future population-based studies of HPV infection in Puerto Rico and as an HPV screening method in women.

Diagnostic accuracy of liquid‐based endometrial cytology in the evaluation of endometrial pathology in postmenopausal women

The aim of this study was to compare liquid-based endometrial cytology with hysteroscopy and endometrial biopsy regarding its diagnostic accuracy in a series of postmenopausal women with abnormal uterine bleeding (AUB) or asymptomatic women with thickened endometrium assessed by transvaginal ultrasound as a screening procedure. Inclusion criteria were: menopausal status; the presence of AUB and/or thickened endometrium assessed by ultrasound (cut-off 4 mm); a normal Papanicolaou (Pap) smear; and no adnexal pathology at ultrasound. Exclusion criteria were: previous endometrial pathology; and previous operative hysteroscopy. Of 768 postmenopausal women referred to our general gynaecology clinics, 121 fulfilled the inclusion criteria and were recruited to the trial. Twenty-one refused to participate. Cytological sampling was carried out by brushing the uterine cavity using the Endoflower device with no cervical dilation and the vial was processed using a ThinPrep® 2000 automated slide processor. The slides were stained using a Pap method. In 98 cases with histological biopsies, endometrial cytology detected five cases of endometrial carcinoma, 10 of atypical hyperplasia and 47 of non-atypical hyperplasia; 36 cases were negative. In two cases cytology was inadequate because of uterine cervical stenosis. Taking atypical hyperplasia or worse as a positive test and outcome, the diagnostic accuracy of the endometrial cytology was 93.5%, with a sensitivity of 92% and specificity of 95%, a positive predictive value of 73% and a negative predictive value of 99%. All the carcinomas were detected by cytology. Only 42% of women with a positive diagnosis were symptomatic. The cytological sampling was well tolerated by all patients. No complication was registered. Liquid-based endometrial cytology can be considered an useful diagnostic method in the detection of endometrial pathology as a first-line approach, particularly if associated with transvaginal ultrasound.

How common is adenomyosis? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic

What is the prevalence of adenomyosis in a population of women attending a general gynaecological clinic? Adenomyosis was present in 206 of 985 [20.9%; 95% confidence interval (CI): 18.5-23.6%] women included in the study. Previous studies of occurrence of adenomyosis have been limited to women who underwent hysterectomy, which is likely to overestimate its prevalence compared with the general population of women. There are no large prospective studies on the prevalence of adenomyosis, either in the general population of women or in a general gynaecology clinic setting. This was a prospective observational study set in the general gynaecology clinic of a university teaching hospital between January 2009 and January 2010. There were 985 consecutive women who attended the clinic and underwent structured clinical and transvaginal ultrasound examination in accordance with the study protocol. Morphological features of adenomyosis were systematically recorded with the ultrasound scan to determine its prevalence and factors which may affect its occurrence. Adenomyosis was present in 206/985 [20.9% (95% CI: 18.5-23.6%)] women included in the study. Multivariate analysis showed that the prevalence of adenomyosis was significantly associated with women's age, gravidity and pelvic endometriosis (P< 0.001). In women who subsequently underwent hysterectomy, there was a good level of agreement between the ultrasound and histological diagnosis of adenomyosis [κ = 0.62 (P = 0.001), 95% CI (0.324, 0.912)]. Our estimate of prevalence of adenomyosis is likely to be higher than in the general population as we studied symptomatic women attending a gynaecology clinic. Better estimates of the prevalence of adenomyosis can improve our understanding of the burden of the disease, help to identify women at high risk of developing the condition and facilitate the development of preventative strategies and effective treatment. The authors have no competing interests to declare. The study was not supported by an external grant.

Sexual activity and function in women with and without pelvic floor disorders

We describe differences in sexual activity and function in women with and without pelvic floor disorders (PFDs). Heterosexual women ≥40 years of age who presented to either urogynecology or general gynecology clinics at 11 clinical sites were recruited. Women were asked if they were sexually active with a male partner. Validated questionnaires and Pelvic Organ Prolapse Quantification (POP-Q) examinations assessed urinary incontinence (UI), fecal incontinence (FI), and/or pelvic organ prolapse (POP). Sexual activity and function was measured by the Female Sexual Function Index (FSFI). Student's t test was used to assess continuous variables; categorical variables were assessed with Fisher's exact test and logistic regression. Univariate and multivariate analyses were used to assess the impact of pelvic floor disorders (PFDs) on FSFI total and domain scores. Five hundred and five women met eligibility requirements and gave consent for participation. Women with and without PFDs did not differ in race, body mass index (BMI), comorbid medical conditions, or hormone use. Women with PFDs were slightly older than women without PFDs (55.6 + 10.8 vs. 51.6 + 8.3 years, P <0.001); all analyses were controlled for age. Women with PFDs were as likely to be sexually active as women without PFDs (61.6 vs. 75.5 %, P = 0.09). There was no difference in total FSFI scores between cohorts (23.2 + 8.5 vs. 24.4 + 9.2, P = 0.23) or FSFI domain scores (all P = NS). Rates of sexual activity and function are not different between women with and without PFDs.

Chronic Pelvic Pain Syndrome-Related Diagnoses in an Outpatient Office Setting

Background: Chronic pelvic pain (CPP) is a syndrome composed of one or more pain diagnoses arising from pelvic organs. Although the prevalence of many individual diagnoses has been determined in a variety of settings, the concurrent assessment of overlapping pain syndromes in an outpatient gynecology clinic, which would be most pertinent to practitioners, has not been reported. Methods: Patients waiting to be seen in an outpatient general gynecology clinic completed a survey composed of validated instruments for different pain diagnoses. Cyclic and constant CPP, irritable bowel syndrome (IBS), interstitial cystitis (IC), and vulvodynia (VVD) were assessed. Results: In the 498 completed surveys, 24% of patients met at least one criterion for CPP, and of these, 23% also met criteria for a second diagnosis. Of all patients, 15% reported symptoms consistent with IBS, 6% with IC, and 5% with VVD. Cyclic CPP was found in 20%, and of these patients, 30% had at least one other CPP-related diagnosis. Discussion: Although limited by its design as a survey, this study demonstrates that CPP frequently (between 30 and 43%) occurs with other pain syndromes. Clinicians should be prepared to evaluate nongynecologic causes of pelvic pain.