News I Will Use

Vacation and an afternoon on the front porch with the laptop provides a chance to catch up on my journal reading. Here are a few tidbits from today’s front porch reads that I will likely use clinically –

Acyclovir and Valcyclovir use in the first trimester of pregnancy continues to appear safe.

These drugs are commonly used to treat Herpes. In a little over 1800 exposed pregnancies, the rate of birth defects (2.2%) in pregnancies where these two drugs were used in the first trimester was comparable to non-exposed pregnancies (2.4%). Until now, data has been limited to voluntary registry reports to the FDA of acyclovir exposure –  about 500 exposed pregnancies with reported birth defect rates of about 3% in exposed and non-exposed pregnancies. This study was a review of a large Danish national birth database, and used pharmacy records to assess exposure. Limitations? (1) Pharmacy records may not indicate actual drug exposure; (2) Not enough exposures to assess impact on individual birth defects, just overall rates; and (3) Famcyclovir, another drug commonly used, was used by only 26 women in this study, so conclusions about its comparable safety cannot be drawn.

Using Lubricant for Speculum Insertion

In a commentary in the August Green Journal, Oz Harmanli and Keisha Jones make the case that lubricant, when applied properly, does not interfere with Pap smear interpretation or testing for sexually transmitted diseases, and should be routinely used for pelvic exams.

I usually lubricate the speculum with water, and am generally known for doing gentle exams, but will likely increase my use of lubricant during routine exams after reading this commentary. I remain concerned about my ability to read a wet prep after using lubricant in women presenting with symptoms of vaginitis – the gels can make the slide difficult to read. In addition, the lubricant we use has antibacterial properties, so I still probably will try to avoid using it if I plan to send bacterial or yeast cultures.

Oral Contraceptives Suppress Ovulation Just as Well in Obese as Normal Weight Women

In this well-done study of  20 microgram pill users, ultrasounds and hormone levels were done to determine if and when ovulation might occur during oral contraceptive use. Obese women had no more ovulations than normal weight women. Not surprisingly, non-compliance with daily pill use was the biggest predictor of ovulation during pill use.  An unexpected finding was that obese women missed more pills, although they did not always report this to the investigators.

Uterine Artery Embolization vs Hysterectomy – 5 year health outcomes

Uterine Artery Embolization or UAE (also called Uterine Fibroid Embolization or UFE) is a emerging alternative to surgical treatment of uterine fibroids. In UFE, small microspheres are injected via a catheter to block the blood vessels feeding the fibroids, causing them to shrink in size. This study randomized 197 women 1:1 to either hysterectomy or UFE. Five years later, health-related quality of life was similar between the two groups, although about 25% of those who underwent UFE ended up eventually having a hysterectomy.  I offer both treatments to my patients, along with hormonal options if they exist, but most of my patients choose to live with their fibroids till menopause, when they naturally will shrink.

Ovulation after Medical Abortion

It occurs on average 21 days after start of the procedure. That’s important information to tell patients, and impacts when to start contraception.  (Sober et al ASRM 2010 abstract Fert Steril 2010; 94 (4): S5)

Return to Fertility after D&C vs Misoprostol treatment of Missed Abortion

We are now using misoprostol to help women end pregnancies that have stopped growing but have not yet passed (missed abortion), potentially  saving them from a D&C.  But which procedure allows for faster return to fertility? This is important to know for women undergoing assisted reproduction treatment, as well as for women trying to get pregnant. In this study, the pregnancy test turned negative in about 37 days regardless of which procedure is used to end the pregnancy, and the next fertility cycle occurred about 60 days later. Not surprisingly, about 26% of women using misoprostol end up with a D&C anyway. The ability to obtain material for genetic analysis was predictably higher for D&C. (68% vs 5%) (Cotton et al SARM 2010 abstract Fert Steril 2010; 94 (4): S6-7)

Vaginal vs laparoscopic hysterectomy

Peri-operative outcomes were similar between women randomized to either vaginal hysterectomy or laparoscopic hysterectomy by a single experienced surgical team at this Italian hospital, but post operative pain was better and hospital stays shorter in women having the laparoscopic procedure.  This is an important study because it has been argued that vaginal hysterectomy in experienced hands is as good as the newer laparoscopic procedures. Of course, the study’s findings will have to be replicated by other surgeons and other hospitals before definitive conclusions can be made, and in the end, it is the skill of the surgeon that in my mind, is most important, whether he/she chooses to use the vaginal or laparoscopic approach.

Vaginal probiotics are effective for recurrent bacterial vaginosis

We’ve been looking for a probiotic solution to BV for years, and we may finally have it. These capsules containing lactobacillus rhamnosus, l Acidophius and Streptococcus thermophilus, used nightly every other week for two weeks, were effective at reducing recurrences of bacterial vaginosis from 45% to 15%. The capsules used have very high concentrations of these probiotic bacteria.  This is only the first study of this preparation, so we will need to see if it is replicated by others.

Pelvic Floor Training Works

Even in cases with pre-existing prolapse, the bladder and rectum were elevated and urinary symptoms and bother were reduced after pelvic floor training, with no adverse effects in this randomized parallel group controlled trial. The training regimen was 3 sets of 8-12 muscular contractions daily, supervised by a physical therapist once a week for 3 months, and every other week for another 3 months. The move used is called “the Knack”, in which pelvic floor muscles are tightened before and during increases in intra-abdominal pressure (cough, sneeze, valsalva). What I like about the Knack is that it isolates the pelvic muscle – most women tend to erroneously tighten their abs when we want them to be tightening their pelvic floor.