The definition of a hysterectomy is removal of the uterus. A
brief review of female reproductive anatomy may be of help in understanding
hysterectomy.
The uterus is a hollow pear-shaped muscular organ located in
the lower abdomen or pelvis. One end of each fallopian tube is
contiguous with and opens into the side of the uterus, at the upper
end, and the other end lies next to an ovary. At its lower end,
the uterus narrows and opens into the vagina. The lower end of
the uterus is called the cervix. The ovaries lie lateral to and
slightly behind the uterus.
During a woman's reproductive years, a
small cyst forms in an ovary, and an egg is released by an ovary
each month and enters the fallopian tube, where fertilization
may occur if sperm are available. If fertilization occurs, the
fertilized egg implants in the uterine lining and a pregnancy
is initiated. If the egg is not fertilized by a male sperm, the
woman experiences her "period" as
the uterus sheds its lining (endometrium): the blood and tissue
that had accumulated in anticipation of fertilization and pregnancy.
In addition to producing eggs, the ovaries also produce the hormones
estrogen and progesterone. As menopause develops, hormone production
by the ovaries decreases markedly. The ovaries also stop producing
eggs, and menstrual periods eventually stop.
If the uterus and cervix are removed the
term is a total hysterectomy. The term hysterectomy does not
automatically imply anything about the ovaries. A partial hysterectomy
refers to the fact that the cervix was not removed and is not
a term that designates that the ovaries were or were not left
intact. A separate term for removal of the ovaries is used and
is called an oophorectomy. If the fallopian tubes are removed
with the ovaries, the term is salpingoophorectomy. There ways
to do a hysterectomy and the approach depends on the patient’s
history, the indications for the procedure and the size of the
organ itself.
WHAT IS AN ABDOMINAL HYSTERECTOMY? Abdominal
hysterectomy is a surgical procedure in which the uterus is removed
through an incision in the lower abdomen. One or both ovaries and
fallopian tubes may also be removed during the procedure.
HOW WILL I FEEL AFTER THE SURGERY? Abdominal
hysterectomy is a common and safe procedure, but it is still a
major operation. The woman typically stays in the hospital for
2 days, and should plan a period of several weeks to recover at
home, during which normal activities can gradually be resumed.
Usually, fluids and food are offered soon after surgery. Intravenous
fluids may be administered during the first day, particularly if
the woman experiences any nausea or vomiting. Medications are administered
to manage pain and women are asked to get up and walk soon after
surgery. Regaining mobility is particularly important as it helps
to prevent complications, such as blood clots, pneumonia, and gas
pains.
Once home, the woman is encouraged to resume most normal daily
activities as quickly as is comfortable. She is instructed to call
their doctor if she experiences an increase in pain, persistent
nausea or vomiting, bleeding heavier than a menstrual period, or
any signs or symptoms of infection.
WHAT IS A VAGINAL HYSTERECTOMY? Vaginal hysterectomy
is a surgical procedure in which the uterus is removed through
the vagina. One or both ovaries and fallopian tubes may be removed
during the procedure, as well. A vaginal approach may be chosen
if the uterus is not greatly enlarged, and if the condition prompting
the surgery is benign and limited to the uterus. Studies have shown
that vaginal hysterectomy is associated with fewer complications,
a shorter length of hospitalization, and faster recovery than removal
of the uterus through an abdominal incision (abdominal hysterectomy).
WHAT IS A LAPAROSCOPICALLY ASSISTED
VAGINAL HYSTERECTOMY? Some
surgeons use a laparoscope in conjunction with the vaginal hysterectomy
procedure. A laparoscope is a surgical instrument inserted through
a small incision in the abdomen. Using the scope, the surgeon can
see structures within the abdomen, and, if needed, perform procedures
such as removing scar tissue to aid the vaginal surgery. It is
generally believed that a woman can return to normal activities
sooner after a vaginal hysterectomy than after an abdominal hysterectomy.
As a result, sometimes patients who are candidates for abdominal
hysterectomy may have laparoscopy done to help mobilize the uterus
and allow a vaginal hysterectomy to be done instead. Ask your surgeon
if a laparoscope will be used during your procedure.
IS THERE A CHANCE THAT I WILL HAVE AN
ABDOMINAL HYSTERECTOMY INSTEAD? Although infrequent,
after your surgery has begun, your surgeon may find conditions,
such as extensive scar tissue, that make abdominal hysterectomy
the better choice. Sometimes these conditions are not apparent
before surgery. When this happens, the surgeon stops the vaginal
procedure and changes to an abdominal approach.
Supracervical or subtotal hysterectomy There
are situations in which the entire uterus is not removed. A supracervical,
subtotal, or partial hysterectomy refers to a procedure in which
the cervix is left intact. Sometimes during hysterectomy difficulties
arise which make the surgeon decide that leaving the cervix in
place is safer. Also, some women also prefer keeping the cervix
intact as they feel it will contribute to sexual satisfaction after
hysterectomy.
In rare cases of emergency hysterectomy done to control bleeding
following childbirth, the supracervical procedure may be done because,
in this setting, it can be difficult to identify the boundary of
the cervix (or the point at which the cervix ends and the vagina
begins).
If the cervix is not removed, the woman remains at risk for cervical
cancer and must continue to have routine screening for the disease
(Pap smear). In some women, the retained cervix is attached to
the lower uterine segment and its endometrium, meaning that they
will continue to experience menstrual periods.
Prior to planned supracervical hysterectomy, tests should be
performed to exclude any cervical abnormalities. In addition, the
woman should discuss with her doctor the risks and benefits of
leaving the cervix intact.
Fibroids (leiomyomata) Non-cancerous
tumors of uterine muscle, which may occur in up to a third of all
women, and typically shrink after menopause.
Pelvic relaxation Stretching
and weakening of the pelvic muscles and ligaments that allow the
uterus to sag (or prolapse) into the vagina, thought to be associated
with vaginal childbirth.
Adnexal mass A
mass involving the ovaries or, rarely, the fallopian tubes
Cervical abnormalities Precancerous
abnormalities or cancer of the cervix unresponsive to lesser procedures
such as cone biopsy or treatments using laser or cryosurgery.
Endometrial hyperplasia Excessive
growth of the endometrium or the tissue that lines the uterus.
Some types of endometrial hyperplasia may be precursors of endometrial
cancer.
Malignancy Cancer
affecting the uterus or other reproductive organs
Tuboovarian abscess A
collection of pus and inflamed tissue involving the ovaries and
fallopian tubes
Chronic pelvic pain Chronic
pelvic pain may be due to the effects of endometriosis or scarring
(adhesions) in the pelvis and between pelvic organs or sometimes
as a last resort when all other treatments have failed.
Hysterectomy is always a planned or elective procedure, except
in rare situations. For example, the uterus may be removed following
childbirth to treat severe postpartum bleeding when all other interventions
have not controlled the hemorrhage.
WHAT OTHER TREATMENTS MIGHT BE AVAILABLE
FOR MY CONDITION? In some cases, medicines or
limited surgery can be used to treat an underlying condition
and hysterectomy can be postponed or avoided. The decision
to proceed with the surgery should be made mutually by the
woman and her doctor after careful consideration of the woman's
particular medical problem, all available treatment options,
and the risks and benefits of each type of treatment.
Oophorectomy Oophorectomy
is surgical removal of the ovaries. It is sometimes done in conjunction
with hysterectomy. Some women may have a condition that requires
that the ovaries be removed. Others, however, may be asked to make
a choice between keeping the ovaries or having them removed.
If the woman has not gone through menopause, keeping the ovaries
allows for continued natural production of estrogen and progesterone,
and allows the woman to avoid the need for hormone replacement
therapy immediately after surgery. Removal of the ovaries, however,
essentially eliminates the risk of needing additional operations
for future ovarian problems, and may be desired in some women.
The woman should discuss her individual risks and preferences with
her doctor before surgery.
In women who have completed menopause, the ovaries are frequently
removed as part of the surgery because they are not producing large
amounts of hormones, it is easily accomplished as part of the surgery,
and avoids the need for future surgeries should problems with the
ovaries arise.
WHAT ARE THE POSSIBLE COMPLICATIONS
OF THE SURGERY? A number of complications can
occur as a result of hysterectomy. Fortunately, most can be
easily managed and do not significantly impair the healing
process. Complications associated with hysterectomy include:
Hemorrhage Excessive
bleeding occurs in a small number of cases and may require transfusion
and/or a return to the operating room to identify and correct the
cause.
Infection Fever
after hysterectomy is not uncommon. In some women, the fever
may be due to an infection that is treated with intravenous antibiotics.
Rarely, serious infections that are not eliminated by antibiotics
require further surgery.
Damage to other abdominal structures
or organs The urinary bladder, ureters (small
tubes leading from the kidneys to the bladder), and the large
and small intestine are located in the lower abdomen and can
be damaged during hysterectomy. If injury occurs, it may be
detected and corrected at the time of surgery, usually without
subsequent problems.
Thromboembolism Thromboembolism,
or formation of a blood clot in a blood vessel, is a rare complication
after abdominal hysterectomy. Preventive treatment and postoperative
ambulation help to minimize this risk. Women taking oral contraceptives
should discontinue them one month prior to planned surgery, and
use alternative methods of birth control to minimize the risk of
this complication.
Other complications include protrusion of the small intestine
or prolapse of the fallopian tube into the vagina. These occur
very rarely and can be corrected surgically. As with any surgical
procedure, complications related to anesthesia can also occur.
As with any abdominal operation, there is a possibility of eventually
developing a hernia in the incision site.
WILL I NEED HORMONES AFTER THE SURGERY? Hormone
replacement therapy (HRT) is recommended for women who have their
ovaries removed, if they have not yet completed menopause. If HRT
is planned, talk with the doctor about the risks and benefits of
this treatment, and about how long you will continue to take hormones.
In younger women who retain their ovaries, HRT may be needed
at a later date if the ovaries fail to function properly.
Women who have completed menopause may or may not have been taking
hormones prior to hysterectomy. They should talk with the doctor
as to whether hormones will be needed following removal of the
ovaries.
HOW DOES HYSTERECTOMY AFFECT SEXUAL
FUNCTIONING? Hysterectomy
appears to have few, if any, negative effects on sexual functioning.
In a recent study of 1,000 women undergoing hysterectomy, favorable
effects were found, including an increase in the frequency of sexual
activity and a decrease in problems associated with sexual functioning.
WHERE TO GET MORE INFORMATION Your
gynecologist is the best resource for finding out important information
related to your particular case. Because every patient is different,
it is important that your situation is evaluated by someone who
knows you as a whole person.
INFERTILITY
These materials are for your general information and are not
a substitute for medical advice. You should contact your physician
or other healthcare provider with any questions about your health,
treatment, or care.
INTRODUCTION Infertility is defined as the inability
of a couple to become pregnant after one year of unprotected intercourse.
Infertility is a common condition: in any given year, about 15
percent of the couples in the United States who are trying to conceive
are infertile.
The ability of a couple to become pregnant depends on several
factors in both the male and female partners. Among all cases of
infertility, about 20 percent can be traced to male factors, 40
percent can be traced to female factors, 30 percent can be traced
to factors in both the male and female partners. In about 15 percent
of couples, the etiology for infertility cannot be traced to specific
factors in either partner.
Because fertility involves a complex interaction of male and
female factors, doctors routinely involve both partners in the
evaluation of infertility. Today, many tests are available for
evaluating infertility, although these tests may require a substantial
commitment of time, money, and effort. It is important to gather
information about these tests and to carefully discuss the many
options with your doctor.
LIMITATIONS OF INFERTILITY TESTS In
many cases, infertility tests can identify the most likely cause
of infertility and help guide the treatment of this condition.
However, studies have shown that these tests also have limitations.
For many of these tests, the definition and the significance of
a "normal" result are still uncertain. In general, test
results are more likely to be abnormal in infertile couples than
in fertile couples; however, many couples with abnormal test results
are able to conceive. Your doctor can provide helpful information
about the interpretation of infertility test results.
FACTORS ASSOCIATED WITH INFERTILITY A
study of infertile couples showed that several factors were associated
with infertility, although it is unknown if these factors were
actually the cause of infertility. The factors included male reproductive
problems (23 percent of couples); ovulation problems (18 percent);
damage of the fallopian tubes (14 percent); endometriosis (9 percent),
problems with intercourse (5 percent), and an abnormal interaction
of cervical mucus and sperm (3 percent). In 28 percent of the couples
in this particular study, the cause of infertility could not be
determined.
EVALUATION OF MALE CAUSES OF INFERTILITY Although
a variety of tests are available for evaluating male infertility,
many of these tests may not be necessary. Doctors usually begin
with a medical history, a thorough physical examination, and semen
analysis.
Medical history Your past health
and medical history may provide clues about the cause of infertility.
Your doctor will ask about your childhood development; sexual development
during puberty; sexual history; illnesses and infections; surgeries;
drugs that you may take; exposure to certain environmental agents
(alcohol, radiation, steroids, chemotherapy, and toxic chemicals);
and any previous fertility evaluations that you may have had.
Physical examination A physical
examination usually includes a general medical examination, with
special attention to any signs of hormone deficiency or signs of
other conditions that might impair fertility. Your doctor will
measure your height and weight, assess your body fat and muscle
distribution, inspect your skin and your hair pattern, and check
for any breast development. Your doctor will also perform a genital
exam, which can identify structural abnormalities of the reproductive
tract and signs of delayed sexual development or low hormone levels.
Standard semen analysis Standard
semen analysis can provide information about the volume and pH
of semen; the concentration, motility (movement), and shape of
sperm; the presence of immature sperm; and the presence of other
substances and cells that affect fertility.
Your doctor will usually request that you abstain from sex for
at least 2 days before providing the semen sample. Ideally, a sample
should be produced in your doctor's office by masturbation, but
if that is not possible, you may be allowed to collect a sample
at home in a chemical-free condom and deliver it to the lab within
an hour of collection. If the result is abnormal, your doctor will
request two additional samples several weeks apart to confirm whether
or not there is a problem.
Men with a sperm count below 20 million/mL are more likely to
be infertile; however, many men with sperm counts in this category
are fertile. There are no standard measures for the motility and
shape of sperm, but studies in infertile men who have later fathered
children have provided some general estimates of the values associated
with fertility. In these men, more than 40 percent of sperm had
a motility of 2.5 or greater (on a scale of 0 to 4), and more than
30 percent of sperm had the normal oval-shaped head.
Blood tests Blood tests can
provide information about the levels of several hormones that play
a role in male fertility; in men, key hormones are produced by
the hypothalamus, the pituitary gland, and the testes. The hormone
levels and the overall pattern can determine if these structures
are functioning normally. These tests are only performed if the
semen analysis is abnormal.
Genetic tests If your doctor
suspects genetic or chromosomal abnormalities are contributing
to infertility, he or she may order a test to check for missing
or defective regions of genes and chromosomes.
Other tests If your doctor
suspects an obstruction of the reproductive tract, he or she may
order a transrectal ultrasound (TRUS) test. This test can identify
blocked regions of the male reproductive tract. Your doctor may
also request a postejaculatory urine test if retrograde ejaculation
(movement of semen in the wrong direction in the reproductive tract)
is a possibility. Your doctor may also recommend a testicular biopsy
(collection of a small tissue sample) to examine the microscopic
architecture of the testes and to directly check for sperm production.
EVALUATION OF FEMALE CAUSES OF INFERTILITY — Although
a variety of tests are available for evaluating female infertility,
many of these tests may not be necessary. Doctors usually begin
with a medical history, a thorough physical examination, and some
preliminary tests.
Medical history Your past health
and medical history may provide some clues about the cause of infertility.
Your doctor will ask about your childhood development; sexual development
during puberty; sexual history; illnesses and infections; surgeries;
drugs that you may take; exposure to certain environmental agents
(alcohol, radiation, steroids, chemotherapy, and toxic chemicals);
and any previous fertility evaluations that you may have had.
Physical examination A physical
examination usually includes a general medical examination, with
special attention to any signs of hormone deficiency or signs of
other conditions that might impair fertility. Your doctor will
also perform a pelvic examination, which can identify structural
abnormalities of the reproductive tract and signs of low hormone
levels.
Blood tests Blood tests can
provide information about the levels of several hormones that play
a role in female fertility; in women, key hormones are produced
by the hypothalamus, the pituitary gland, and the ovaries. These
hormones include follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and prolactin.
Tests to evaluate ovulation Ovulation
(the release of an egg from an ovary) is essential for fertility.
Abnormalities of ovulation can often be determined from a woman's
menstrual history, her basal body temperature tracking, or hormone
levels such as the pre-ovulatory LH surge or luteal phase progesterone.
Menstrual history Amenorrhea
(absent menstrual periods) usually signals an absence of ovulation,
which is a known cause of infertility. Oligomenorrhea (irregular
menstrual cycles) can signal erratic ovulation; although oligomenorrhea
does not make pregnancy impossible, it reduces the likelihood of
pregnancy.
Basal body temperature Monitoring
of basal body temperature (measured early in the morning when body
temperature is at its lowest point) can help determine if ovulation
is occurring. This temperature usually rises by 0.5ºF to 1.0ºF
after ovulation. However, basal body temperature patterns can sometimes
be difficult to interpret.
Hormone levels Levels of luteinizing
hormone (LH) rise abruptly approximately 38 hours before ovulation.
This hormone surge can be detected using an over-the-counter urinary
test kit. However, this kit may fail to detect the hormone surge
about 15 percent of the time. Therefore, your doctor may recommend
a blood test to confirm ovulation.
Blood levels of the hormone progesterone
are a more accurate indicator of ovulation. Normally, levels
of progesterone rise after ovulation. Progesterone tests are
usually performed 18 to 24 days after the first day of a menstrual
period.
Hysterosalpingography This
procedure can help identify structural abnormalities of the uterus
and fallopian tubes that can contribute to infertility. During
hysterosalpingography, a liquid dye is placed in the uterus and
fallopian tubes to outline these structures on x-rays; hysterosalpingography
is usually performed after the completion of a menstrual period,
but before ovulation.
Hysteroscopy During hysteroscopy,
a thin, lighted tube is advanced into the uterus and fallopian
tubes to directly examine these structures. A hysteroscopy is usually
performed in women who are thought to have an abnormal uterine
cavity on hysterosalpingography or ultrasound; several structural
abnormalities can be surgically treated during hysteroscopy.
Uterine abnormalities Uterine
abnormalities that can contribute to infertility include congenital
structural abnormalities, such as a uterine septum (a band of tissue
that makes the uterine cavity small); abnormalities linked to exposure
to diethylstilbestrol (DES) (a hormone used in the past to prevent
miscarriage), which can cause a T-shaped uterus; fibroids; polyps;
and structural abnormalities that can result from gynecologic procedures.
Fallopian tube abnormalities Scarring
and obstruction of the fallopian tubes is most often due to pelvic
inflammatory disease. Other conditions that can affect the function
of the fallopian tubes include endometriosis and pelvic adhesions
(scar tissue) from abdominal infection or surgery.
Pelvic ultrasound Pelvic ultrasound
can also detect structural abnormalities of the uterus, ovaries,
and other pelvic tissues and organs.
Laparoscopy During laparoscopy,
a thin, lighted tube is advanced through a small abdominal incision
to directly examine the pelvic structures. This test can detect
damage and obstruction of the fallopian tubes, endometriosis, and
other abnormalities of the pelvic structures.
Laparoscopy is the best test for making the diagnosis of endometriosis
or pelvic adhesions (scarring). Furthermore, endometriosis tissue
can be removed during laparoscopy, and this removal has been shown
to improve pregnancy rates in infertile women.
Your doctor will likely recommend laparoscopy if you have had
endometriosis, appendicitis, pelvic surgery, pelvic inflammatory
disease, or other conditions known to affect the fallopian tubes
or uterus. Laparoscopy is also helpful when other tests fail to
reveal a cause of infertility.
Genetic tests If your doctor
suspects genetic or chromosomal abnormalities are contributing
to infertility, he or she may order a test to check for missing
or defective regions of genes and chromosomes.
WHERE TO GET MORE INFORMATION A
doctor is the best resource for finding out important information
related to your particular case. Not all patients with infertility
are alike, and it is important that your situation is evaluated
by someone who knows you as a whole person.
INTRODUCTION — Women
of childbearing age and their partners should be offered preconceptional
evaluation and counseling. This information will help prepare
patients for pregnancy, can benefit the fetus, and may also lead
to a more healthy lifestyle for the patient. The United States
Public Health Service Expert Panel on the Content of Prenatal
Care recommended that efforts to help women and their partners
prepare for pregnancy should be an important part of prenatal
care and that such care should be included in all primary care
services.
Up to 30 percent of pregnant women begin
traditional prenatal care in the second trimester (>13 weeks
of gestation), after the period of maximal organ development
(between 3 and 10 weeks gestation). However, optimizing the health
of the mother before conception is important for improving pregnancy
outcome. This is particularly true for certain populations of
women, such as those with medical disorders (eg, diabetes, phenylketonuria),
nutritional deficiencies (eg, folic acid), and exposure to toxins
or substances that can cause birth defects and abnormalities,
also known as teratogens (eg, cigarettes, alcohol, warfarin,
accutane), in whom preconception care has been shown to reduce
neonatal morbidity and mortality. As an example, of the 4000
pregnancies affected by neural tube defects each year in the
United States, at least 50 percent have been estimated to be
preventable by the use of daily folic acid before conception
and during early pregnancy.
Thus, preconceptional evaluation and counseling provide an opportunity
to identify some of the risks of pregnancy for the mother and fetus,
educate the patient about these risks, and institute appropriate
interventions, when possible, before conception. Potential opportunities
for preconceptional counseling occur during many non-emergency
health care encounters, including:
Premarital examination and testing
Contraception counseling
Evaluation for sexually transmitted
disease or vaginal infection
After a negative pregnancy test
Anytime a woman of childbearing
age presents for a periodic health examination.
Risk factors for adverse outcome that cannot be modified (eg,
maternal age).
Financial issues (eg, lack of health insurance,
nonreimbursible services)
Inadequate training of health care
providers and long wait for appointments
Unplanned pregnancy One-third
to one-half of liveborn infants are the result of unintended pregnancy.
In one study, for example, 40 percent of the mothers surveyed three
to six months after delivery reported that their pregnancy was
unplanned. One-half of women who planned their pregnancy and two-thirds
of the mothers with unintended pregnancies had one or more indications
for preconceptional counseling (smoking within three months of
pregnancy, drinking three or more drinks within three months of
pregnancy, low body mass index, or delayed initiation of prenatal
care [after the first trimester]). These findings suggest that
preconceptional counseling should be provided to all women of childbearing
age, regardless of their immediate pregnancy plans.
Financial issues Preconceptional
counseling may not be fully reimbursed by third-party payers. Many
insurers currently do not provide coverage for screening tests
as part of preconceptional counseling, although these same tests
are covered when performed in early pregnancy. Furthermore, a number
of low income women have multiple risk factors for adverse pregnancy
outcome and are less knowledgeable about pregnancy and health.
These women often do not have any health insurance and, therefore,
may be reluctant to seek preconceptional care. Difficulties with
child care and transportation are also barriers to access services.
Provider factors All women's
health care providers should be trained to perform adequate assessment
of pregnancy risks, offer appropriate recommendations for intervention,
and provide basic patient education. Certain situations should
prompt consideration of referral to genetic counseling or specialty
care.
Lack of coordination among providers of women's health services
can be a barrier to optimum care. Healthcare systems that develop
strategies to provide more culturally competent care, more timely
appointments, and assistance with insurance applications may be
able to increase the number of women seeking early prenatal services.
Patient education
regarding pregnancy risks, management options, and reproductive
alternatives
Initiation of interventions, when possible, to
provide optimum pregnancy outcome.
Risk assessment The key task
in identifying risks to the woman and her pregnancy is to obtain
a thorough history. Several paper and computerized questionnaires
and record forms are commercially available for this purpose. Patient
education and medical interventions can subsequently be initiated
using this database.
Medical history A complete medical
history is useful for discussing how pregnancy can affect maternal
medical conditions and the effect of a medical disorder on the
fetus and pregnancy. The patient's medications (including over-the-counter
and prescription drugs) should be discussed to determine whether
potentially teratogenic substances are being used. It is especially
important to elicit exposure to dietary supplements (eg, herbal
supplements), as patients may not perceive them as medications
that can be harmful to the fetus. A dietary evaluation also should
include an assessment of body mass index and eating habits (eg,
food restrictions).
Age Advanced maternal age is
associated with increased pregnancy risks that include infertility,
fetal chromosomal abnormalities, gestational diabetes, preeclampsia
(formerly called toxemia), and stillbirth. Women should be aware
of these risks and the consequences of delaying conception until
they are over 35 years of age.
Reproductive history The gynecologic
and obstetric histories are important for identifying factors that
may contribute to infertility or complications in a future pregnancy.
Uterine anomalies or maternal in-utero diethylstilbestrol exposure,
for example, can be associated with pregnancy wastage or preterm
birth. The recurrence risk of an adverse outcome (eg, preterm birth,
intrauterine growth restriction, preeclampsia) should be discussed
with women who have a history of pregnancy complications.
Family history Evaluation of
the patient's family history helps to identify genetic risks to
the fetus and maternal medical risks that may not have been appreciated.
As an example, a woman may not be aware that a family history of
blood clots can put her at risk for thromboembolic and pregnancy
complications. For those with a positive family history, referral
to a specialist in genetic counseling is usually required to discuss
carrier testing, the risk of genetic disease in the fetus, options
regarding prenatal diagnosis, and the natural course of the disease.
Substance abuseExposure to
tobacco, alcohol, and illicit drugs can be harmful to both the
mother and fetus.
Use of tobacco in pregnancy has been associated with several
adverse outcomes, including miscarriage, prematurity, and low birth
weight [
A spectrum of birth defects related to alcohol intake during
pregnancy may occur, ranging from subtle growth retardation
and neurobehavioral effects with moderate alcohol intake,
to the fetal alcohol syndrome with heavy use.
Illicit drugs
have variable effects on pregnancy outcome that may be related
to social disturbances in the mother, in addition to effects
of the drugs themselves.
Psychosocial status Psychosocial
stress and financial issues should be identified and appropriate
interventions taken with the help of a community resource specialist.
It is particularly important to screen for the presence of domestic
violence, lack of social support, and barriers to prenatal care
Environmental exposures Questions
about the woman's work, hobbies, pets, and home environment can
identify potentially toxic exposures. Examples of such hazards
include organic solvents used in manufacturing processes, toxoplasmosis
risk from cat litter boxes or eating under-cooked meat, and lead
paint or solder used for decorating or in crafts. There is no convincing
evidence that exposure to common types of electromagnetic field
radiation, such as computer monitors, electric blankets, heated
water beds, and microwave ovens, is harmful.
The Occupational Safety and Health Administration (OSHA) sets
and enforces standards requiring employers to provide a workplace
free from recognized hazards likely to cause serious physical harm.
This information should be available at the patient's workplace.
Caffeine Caffeine consumption
over 250 mg per day appears to be associated with a modest, but
statistically significant decrease in fertility and intake greater
than 500 mg daily appears to increase the risk of spontaneous abortion.
Excess coffee consumption may also increase the risk of stillbirth
(four to seven cups OR 1.4 (95 percent CI 0.8 to 2.5), eight or
more cups and decrease birth weight slightly. For these reasons,
women planning pregnancy should consider limiting daily caffeine
intake to less than 250 mg.
Weight Maternal obesity has
been associated with reduced fertility and several pregnancy complications,
such as increased risks of gestational diabetes, having a child
with a congenital anomaly, and pre-eclampsia. Although weight loss
to reduce pregnancy risks has not been studied (except in women
with polycystic ovary syndrome), the clear overall health benefits
of achieving a normal body mass index have been well described.
Physical examination — The
physical examination in the preconceptional evaluation is the same
as for the routine periodic health evaluation
Laboratory assessment The choice of laboratory
tests depends upon the general guidelines recommended for all pregnant
women and the individual's personal medical history.
Interventions After the pregnancy
risk assessment is performed, preconceptional interventions are
directed at preparing and educating the patient, providing optimum
therapy of medical disorders, and referral for specialized care,
when appropriate.
Maternal medical problems Optimal
management of maternal medical conditions, including changes in
medications to incorporate medications known to be safer in pregnancy,
is an important step.
Substance use Smoking cessation
and reduction during pregnancy improves pregnancy outcome. Women
who are smokers can be counseled on the benefits of smoking cessation
and offered resources to help them quit smoking.
Women who drink alcohol should be counseled to abstain during
pregnancy since there are no data that establish a safe threshold
for alcohol consumption. Patients who have problems with substance
abuse should be strongly advised of the risks of this behavior
and referred to cessation programs in their area.
Depression and psychotropic drugs Patients
with a history of depression or active symptoms of depression should
be treated, if necessary, with drug therapy. Most of the commonly
used psychotropic agents appear to be relatively safe during pregnancy.
Nutrition A
nutritionist may be consulted to evaluate restricted diets or
to offer advice on eating a well-balanced, healthy diet. Megavitamins,
non-essential dietary supplements, and herbal preparations should
be discontinued given the unknown risk to the fetus from such
substances. All women should be counseled to take a multivitamin
with at least folic acid (0.4 mg) to reduce the risk of neural
tube defects. The optimal dose of folic acid to prevent as many
neural tube defects as possible is not precisely known. The United
States Preventive Services Task Force recommends a folic acid
supplement of 400 micrograms/day (the RDA) for all women in the
childbearing years. However, doses well above this amount may
be necessary to maximally reduce the risk of neural tube defects;
therefore, many authorities recommend a supplement containing
800 micrograms for women trying to conceive. Multivitamin preparations
containing more than 5000 IU of vitamin A should be avoided (increased
risk of birth defects at >10,000
IU/day).
The quantity and type of fish consumed should also be regulated
and certain types of fish should be avoided during pregnancy and
the preconceptional period due concerns about possible teratogenic
effects from environmental toxins. Only cooked fish should be eaten.
Exercise Mild to moderate exercise
is not harmful to the healthy pregnant woman or her fetus. Women
who exercise regularly prior to pregnancy may continue with their
usual level of physical exertion during pregnancy. Initiation of
strenuous exercise during pregnancy, on the other hand, should
be avoided.
Immunization Ideally, a woman
should be immune to or immunized against infections that place
her or her fetus at risk. These diseases vary by country and personal
risk factors
Vaccination should be offered to a woman with a negative rubella
titer and she should be advised to wait three months before attempting
conception since this is a live attenuated virus vaccine.
Varicella (chicken pox) infection during pregnancy can be associated with significant
maternal and fetal morbidity and mortality. Not surprisingly, then, many have
suggested screening women prenatally for evidence of prior varicella exposure
in an effort to identify those who are varicella susceptible. A history of
varicella infection is generally reliable. Women who deny a history of clinical
disease should be offered blood testing; most of these women will have a positive
titer due to prior shistory without symptoms. A strategy of vaccinating those
with a negative titer has been found cost effective. Women with high risk of
exposure, such as health care workers, should definitely be vaccinated. Women
who receive varicella vaccine, a life attenuated vaccine, should be advised
to avoid pregnancy for three months.
Patients at risk for hepatitis B infection (eg, women with multiple sexual
partners, household contacts of patients with hepatitis B, healthcare workers)
should be offered hepatitis B vaccine.
HIV infection Women
of childbearing age who are HIV positive should all be offered
preconceptional counseling, with specific emphasis on a thorough
discussion of the risk of transmission of HIV to the neonate and
how the risk can be modified.
Other concerns Additional
common concerns that may be addressed at this time include:
Timing the initial pregnancy and interval between pregnancies.
Concerns about infertility
Fears concerning the pregnancy
Work related issues and maternity leave
Marital issues.
MENOPAUSE
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care.
WHAT IS MENOPAUSE? Prior
to menopause, (which usually occurs between the ages of 45 and
55), many women notice that their periods start to occur more frequently
(as often as every 21 days), but eventually become infrequent.
This time of "transition," called perimenopause, can
last for several years until menopause, when periods stop altogether.
Although the average age of menopause is between 50 and 51 years,
some women experience unusually early menopause (before age 40)
due to surgical removal of the uterus or both ovaries, chemotherapy,
or radiation therapy. However, most cases of early menopause are
unexplained.
With the onset of menopause, a woman's body stops making estrogen
and progesterone. Estrogen and progesterone are the female hormones
produced by the ovaries that prepare the uterus for possible pregnancy.
Hot flashes (or hot flushes), a result of a fall in estrogen levels,
often begin several years before actual menopause and continue
for several years after menopause. They are far more common at
night, and can disrupt sleep. Therefore, many women also experience
symptoms related to sleep-deprivation, such as fatigue, irritability,
difficulty concentrating, and mood swings. Finally, many women
begin to experience vaginal dryness or urinary symptoms, both of
which are related to estrogen deficiency. Estrogen is the most
effective treatment available for hot flashes, symptoms related
to sleep-deprivation and vaginal dryness.
Estrogen has important effects on many other organs, such as
the brain, skin, blood vessels, heart, bone, and breast. Of particular
importance is bone and possibly cardiovascular (heart) health.
Without estrogen, the body is at greater risk of developing osteoporosis,
a disease in which bones lose calcium and become more susceptible
to fracture. In addition, the risk of heart disease in women increases
after menopause, although giving back estrogen (hormone replacement
therapy) has not been shown to prevent heart disease.
WHAT IS ESTROGEN REPLACEMENT THERAPY? —Estrogen
replacement therapy also called ERT, is a way for a postmenopausal
woman to replace the estrogen her body is no longer making. While
it does not make her fertile again, it does eliminate many of the
symptoms of menopause. When women with a uterus take estrogen they
also need to take a progesterone-like hormone (called progestins)
to eliminate the risk of uterine (endometrial) cancer. The term
hormone replacement therapy (HRT) is used when estrogen and progestin
are given together.
HISTORY OF HRT USE — Estrogen
first became popular in the 1960's for the treatment of hot flushes.
At that time, it was also thought that estrogen was a way to preserve
a youthful appearance. Early on, high doses of estrogen were given
(for example, 2.5 mg of conjugated estrogen compared to the standard
0.625 mg dose that is currently used). Since then, the regimens
and the reasons for taking it have been evolving.
It was learned that taking estrogen alone
resulted in an increased risk of endometrial cancer (also known
as uterine cancer).
It was then determined that adding a progestin
to estrogen could prevent the increased endometrial cancer
risk. Therefore, by the mid-1980's, progestins were routinely
added to estrogen replacement therapy (in any woman with an intact
uterus, ie, women who had not undergone a hysterectomy).
Many
studies showed that taking ERT or HRT could prevent the bone
loss that occurs after menopause, which can lead to osteoporosis
and its fractures.
Over 30 studies suggested that estrogen was
an important therapy for both primary (an intervention designed
to prevent a disease from occurring in the first place) and
secondary prevention (an intervention designed to prevent the
recurrence of problems in someone who already has the disease)
of coronary heart disease (CHD). In fact, it appeared that women
taking estrogen reduced their risk of a first heart attack by
50 percent. In addition, estrogen appeared to reduce recurrent
events in women who already had coronary disease.
Because of the
osteoporosis and CHD studies, ERT and HRT began to be prescribed
for the prevention of both diseases, which meant giving it
long-term (more than 5 years).
Breast cancer studies began to
indicate that taking ERT more than 5 years increased the risk
of breast cancer.
Clinical trials, (studies in which women are
randomly assigned to receive active treatment or placebo),
did not agree with the earlier studies. The Women's Health Initiative
(WHI) and the HERS trials (of combined estrogen-progestin therapy),
studies of primary and secondary prevention of heart disease,
respectively, demonstrated that HRT did not prevent heart disease,
and in fact, might increase risk. The WHI trial of combined
estrogen-progestin therapy did observe an increased risk of breast
cancer, but no increase was seen in the trial of unopposed estrogen.
One possible explanation
for the conflicting results between the observational studies
and clinical trials, is that the observational studies had a
problem with "healthy user bias".
This means that the healthiest women (ie. those who were less
apt to have a heart attack), were more likely to be started on
estrogen by their physicians. Therefore, it is possible that
estrogen's beneficial effect on the heart was more related to
the underlying health of the women taking it, rather than the
medication itself.
WOMEN'S HEALTH INITIATIVE — The
Women's Health Initiative (WHI) is a set of clinical trials that
includes two HRT trials. The WHI studied healthy postmenopausal
women aged 50 to 79 years, and the study was scheduled to be completed
in 2005. However, one component of the WHI (continuous, combined
conjugated estrogen (CEE 0.625 mg/day) and medroxyprogesterone
acetate (MPA 2.5 mg/day) versus placebo in over 16,000 women) was
discontinued in 2002 because of an increased risk of coronary heart
disease, breast cancer, stroke, and venous thromboembolism (blood
clots in the leg or lung) over an average follow-up of 5.2 years.
Although there was reduction in risk of osteoporotic fractures
and colon cancer, there was concern that the risks of combined
estrogen-progestin may outweigh the benefits.
The WHI trial of unopposed estrogen (CEE 0.625 mg/day) versus
placebo in women who had undergone hysterectomy (and therefore
did not require a progestin) was also discontinued (early 2004)
because of a small increase in stroke risk (but no increase in
CHD or breast cancer risk).
Only one type of estrogen (CEE 0.625 mg) and one type of progestin
(MPA 2.5 mg) treatment were studied in the WHI brand names Premarin
(unopposed estrogen) and Prempro (estrogen combined with progestin).
Although there are theoretical reasons to believe that other types
of estrogen and progestin, different routes of administration (skin
patch) or lower doses might be safer, to date, there are no studies
to demonstrate that this is true.
The results of the WHI were as follows:
Coronary heart disease — The
rate of coronary events such as heart attacks was 24 percent higher
in the women taking HRT compared to those taking placebo. This
seems like a large increase in risk, but the increase for an individual
woman is low. For example, on average there were 39 CHD events
per year per 10,000 women versus 33 events per 10,000 women taking
placebo (ie, an additional 6 events per 10,000 women per year).
The difference in coronary events developed within the first
year of the study. The risk persisted in years two through five
of the study, but the highest risk was in the first year. Taking
a daily aspirin did not seem to reduce the risk.
In contrast, the WHI trial of unopposed estrogen did not observe
an increase in CHD risk. In the younger women in the trial (ages
50-59), a possible protective effect was seen with estrogen (although
this was not significant).
Secondary prevention was evaluated in the HERS trials of 2763
postmenopausal women with a history of coronary disease .
After nearly 7 years of follow-up, continuous estrogen-progestin
therapy did not reduce the risk of CHD events in women with established
CHD.
Stroke — The
rate of stroke was increased with combined estrogen-progestin.
On average per year, there were 29 strokes in the treatment group
versus 21 events in the placebo group per 10,000 women (8 additional
cases per 10,000 women per year). Most of the increase in risk
was due to nonfatal strokes, and the increase did not appear
until year two of the study (but persisted through year five).
A very similar pattern of risk was seen in the trial of unopposed
estrogen)
Blood clots — The
rate of blood clots (in the leg and lung) increased with combined
estrogen-progestin (34 versus 16 per 10,000 women per year; or
18 additional cases per 10,000 women per year). Risk was also
increased with unopposed estrogen.
Breast cancer — The
risk of breast cancer was increased in the WHI trial of combined
estrogen-progestin. On average, per year there were 38 cases
of breast cancer per 10,000 women versus 30 per 10,000 women
(8 additional cases per year per 10,000 women). Similar findings
have been noted in a number of observational studies, all of
which suggest that the major increase in risk occurs after four
or five years. In addition, the WHI reported that women taking
combined estrogen-progestin were more likely to have an abnormal
mammogram. However, the majority of the abnormal mammograms were
requests to return for additional views.
The results of the trial of unopposed estrogen were quite surprising,
because no increase of breast cancer was seen. In fact, a possible
lower risk was seen, but this was not quite significant. The fact
that an increase in breast cancer risk was seen with combined hormone
therapy, but not with unopposed estrogen suggests that the progestin
component is a very important factor in breast cancer risk.
Osteoporotic fracture — The
risk of osteoporotic fracture was reduced at the hip and spine
in both the trial of combined estrogen-progestin and the trial
of unopposed estrogen. On average, per year there were 5 fewer
hip fractures per 10,000 women in the HRT versus placebo group.
Colorectal cancer — The
risk of colorectal cancer was reduced (6 fewer colorectal cancers
per 10,000 women per year in the trial of combined estrogen-progestin
versus placebo group. This benefit was not seen in the trial of
unopposed estrogen.
Cognitive function and dementia — Although
it had been thought that estrogen may preserve cognitive function
and prevent dementia, data from the WHI do not support this. No
significant improvement in overall cognitive function was seen
with combined estrogen-progestin therapy compared with placebo.
It is still possible, however, that there are benefits for certain
specific types of cognitive function, although this is not proven.
The impact of unopposed estrogen, or taking HRT in the early postmenopausal
years is not known.
In addition, combined estrogen-progestin therapy did not prevent
dementia. To the contrary, an increased risk was seen (approximately
23 additional cases of dementia per 10,000 women per year). It
is not known why dementia risk was higher with hormone therapy,
but one possible explanation is an increased risk of multiple small
strokes (which predisposes women to dementia). Similar results
were reported in the unopposed estrogen trial. The effect of taking
HRT in the early menopausal years on the risk of later dementia
is not known, although many early studies suggest that it is early,
rather than late, exposure to estrogen is important for later cognitive
function.
Endometrial hyperplasia and cancer — Studies
have found that postmenopausal women with a uterus who are treated
with estrogen alone increase their risk of endometrial cancer and
hyperplasia (a precursor to cancer). Within one year, endometrial
hyperplasia can be found in 20 to 50 percent of women receiving
estrogen alone. The risk can be even greater if very high doses
are used or if the unopposed estrogen is continued for many years.
Even when women discontinue the estrogen, the endometrial cancer
risk persists for approximately five years.
In the WHI, only women without a uterus received unopposed estrogen.
In women with a uterus who received combined estrogen-progestin
therapy, there was no increased risk of endometrial hyperplasia
or cancer.
Absolute risk of an adverse event — It
should be emphasized that the absolute risk of an adverse event
occurring in an individual on the estrogen-progestin regimen in
the WHI was extremely low (19 additional events per year per 10,000
women with HRT compared to placebo).
In the trial of unopposed estrogen, it was calculated that overall
risks and benefits would be equal (not taking into account the
effect that estrogen has on hot flashes).
Most now agree that using either unopposed estrogen or combined
estrogen-progestin therapy for symptom relief in young postmenopausal
women in a safe and reasonable option.
OTHER RISKS — There
are many HRT studies in addition to the WHI that provide other
information about breast cancer. In addition, there are other
known risks of HRT such as gallbladder disease that were not
addressed in the WHI report.
Other breast cancer issues — The
degree of increase in breast cancer risk due to estrogen is often
misinterpreted. It is most important for a woman to understand
the absolute risk that she will get breast cancer because she takes
estrogen. It has been calculated that for a 50-year-old woman taking
estrogen, there is a 1 in 100 chance that she will develop breast
cancer over a 10-year period that would not have developed without
estrogen. This estimate would be slightly higher (eg, 1.5 in 100)
for a woman over 65 years of age.
Many studies have reported that if breast cancer does occur during
estrogen therapy, it is biologically less aggressive, and survival
rates are better than when breast cancer occurs in women who were
not taking estrogen. However, in the WHI combined estrogen-progestin
trial, women on hormones had tumors that were slightly larger and
more likely to have spread to the lymph nodes. As mentioned above,
no increase in breast cancer risk was seen in the trial of unopposed
estrogen.
Gallbladder disease — There
is considerable evidence that estrogen therapy, especially in pill
form, is associated with an increased risk of gallbladder disease.
The risk of cholecystectomy, (removal of the gallbladder), increases
the longer a woman uses hormone therapy and the higher the dose
of estrogen used. The risk decreases substantially within one to
three years after a woman discontinues hormone therapy.
OTHER BENEFITS — In
addition to easing the symptoms of menopause, ER/HRT has many
other positive effects.
Menopausal symptoms — Estrogen
is the most effective treatment available for symptoms such as
hot flashes, urinary symptoms, and vaginal atrophy (atrophic vaginitis),
a condition in which the vagina can become dry, resulting in pain
with intercourse.
Quality of life — Women
with severe menopausal symptoms often describe a dramatic improvement
in their quality of life when they are treated with estrogen. This
is due to relief of hot flushes and restoration of normal sleep.
Urinary tract infection — Estrogen
has been found to decrease the frequency of urinary tract infections,
possibly by normalizing the microorganisms present in the vagina.
It does not help the symptoms of urinary incontinence.
Diabetes mellitus — The
WHI reported that HRT appears to reduce the risk of type 2 diabetes
mellitus (adult onset diabetes). However, because of the other
risks of HRT, this effect is insufficient to recommend HRT for
routine diabetes prevention in postmenopausal women.
Depression — Estrogen
may improve mood and decrease depression in some menopausal women.
One study showed that estrogen plus progestin was effective in
perimenopausal women with depression.
WHO SHOULD TAKE HRT? — Data
from the WHI and the HERS trials have led to changes in our recommendations
for hormone therapy. Continuous estrogen-progestin therapy appears
to increase the risk of cardiovascular events and breast cancer;
in addition, other drugs (eg, bisphosphonates, raloxifene) can
protect against osteoporosis. Unopposed estrogen increases the
risk of stroke, but overall, its benefits seem equal to its risks.
As a result, the main reason to take hormone therapy at present
is to control menopausal symptoms.
Menopausal symptoms — Estrogen
or combined estrogen-progestin therapy remains the gold standard
for relief of menopausal symptoms, and therefore is a reasonable
option for most postmenopausal women, with the exception of those
with a history of breast cancer, CHD, a previous blood clot or
stroke, or those at high risk for these complications. In otherwise
healthy women, the absolute risk of an adverse event is extremely
low. Most experts agree that hormone therapy is safe and reasonable
for healthy postmenopausal women who need to take it to relieve
symptoms. When it is used, is should be taken for the shortest
period of time possible.
Administration of estrogen short-term is not associated with
an increased risk of breast cancer, but endometrial hyperplasia
and cancer can occur after as little as six months of unopposed
estrogen therapy; as a result, a progestin must be added in those
women who have not had a hysterectomy.
In women being treated for symptoms, the goal is to eventually
taper and stop the estrogen (unless there is a compelling reason
to continue it long-term). After the planned treatment interval,
the estrogen should be discontinued gradually, for example, by
omitting one pill per week, to minimize recurrence of the menopausal
symptoms.
Low-dose oral contraceptives — A
low-estrogen oral contraceptive (20 µg of ethinyl estradiol)
remains an appropriate treatment for perimenopausal women who seek
relief of menopausal symptoms. Most of these women are between
the ages of 40 and 50 years and are still candidates for oral contraception.
For them, an oral contraceptive pill containing 20 µg of
ethinyl estradiol provides symptomatic relief, contraception, and
sometimes better bleeding control than conventional estrogen-progestin
therapy.
Dose of estrogen — It
is possible that lower doses of estrogen may be safer than estrogen,
while still effectively treating menopausal symptoms. For example,
conjugated estrogens (0.3 mg) or the equivalent dose of other estrogens
(estradiol, estrogen patch) have been shown in some, but not all
studies to relieve symptoms and prevent bone loss. But it is not
yet known whether lower doses of estrogen or different HRT preparations
are safer with regards to breast cancer and cardiovascular risks.
Therefore, it is safest to assume that other preparations carry
the same risk.
Long-term estrogen therapy — Only
a minority of women who are unable to successfully discontinue
estrogen without persistent symptoms should consider long-term
estrogen therapy. If HRT is resumed, the lowest dose possible should
be used, and plans should be made to try another taper at a later
date. It is important that the breast cancer and cardiovascular
risks are discussed in detail with these women.
WHAT FORM DOES ESTROGEN COME IN? — Estrogen
can be taken as a pill (orally), or absorbed through the skin from
a patch (transdermally), or inserted into the vagina.
Estrogen pill — There
are many forms of estrogen pills. The most commonly used preparation,
called Premarin, is made from pregnant mares' urine. Many other
preparations are derived from plant sources, such as soy and yams.
While there is no evidence that plant-derived estrogens work better
or are safer than Premarin, many women prefer them.
Sometimes the dose of estrogen is large enough to protect bones,
but not to completely eliminate menopausal symptoms. When these
symptoms occur, a larger dose may be given for a year or two, but
then the dose is usually reduced.
Besides Premarin, other brands of estrogen include: Cenestin,
Estratab, Menest, Ogen, Estrace, and Gynediol. While these preparations
vary in their potency and dose amounts, they are all effective.
Estrogen patch — There
are many brands of estrogen patches. Those available in the United
States include: Estraderm, Climara, Vivelle, FemPatch, and Alora.
Some patches need to be replaced every few days, others once a
week.
If an equivalent dose is given, transdermal estrogen is just
as effective as oral estrogens in increasing bone density and in
treating menopausal symptoms. But unlike oral estrogen, it has
not been shown to have a beneficial effect on cholesterol levels.
Vaginal estrogen — Vaginal
estrogen is available as a cream, vaginal ring, or vaginal tablet.
Estrogen cream is inserted into the vagina using an applicator
once a day for two to three weeks. After this, the frequency may
be reduced to one or two times weekly. The estrogen vaginal tablet
(Vagifem) is given on a similar schedule.
The vaginal ring, called Estring, is similar to and a bit smaller
than a diaphragm. It is inserted once every three months and does
not need to be removed during intercourse or bathing. The use of
Estring is favored in women who have trouble using vaginal cream
on a regular basis, or in women with reproductive organs that may
be sagging, called prolapse, who would benefit from additional
support.
Vaginal estrogen is an excellent choice for women who want to
control vaginal dryness, stress incontinence, or frequent urinary
tract infections. But unlike the estrogen in pills and patches,
very little is absorbed by the rest of the body and, as a result,
does not have the other positive or negative effects.
There is one vaginal estrogen product for postmenopausal women
that contains a higher dose of estrogen (Femring). This ring is
designed to be absorbed into the bloodstream and relieve hot flashes.
We do not recommend Femring for women who are taking vaginal estrogen
only to relieve vaginal dryness or urinary symptoms.
WHAT TYPES OF PROGESTIN ARE AVAILABLE? — As
noted above, progestins are now routinely added to estrogen for
any woman with a uterus. The most commonly prescribed progestin
is medroxyprogesterone acetate, available in pill form under the
brand names Provera, Cycrin, or Amen. There are other progestin
preparations, like those used in oral contraceptives, but none
have obvious advantages over medroxyprogesterone. A natural progesterone,
called Prometrium, is now approved by the United States Food and
Drug Administration and appears to be a good alternative for women
who cannot tolerate medroxyprogesterone. In addition, natural progesterone
has no negative effect on lipids, and therefore is a good choice
in women with underlying high cholesterol levels.
ARE THERE ALTERNATIVES TO ERT/HRT? — Not
all women are able or willing to take estrogen replacement, and
alternative therapies are available. These are discussed in detail
elsewhere (See "Patient information: Alternatives to postmenopausal
hormone therapy").
SHOULD WOMEN WITH BREAST CANCER EVER TAKE
ESTROGEN? — Although women with breast cancer
often experience early menopause due to adjuvant chemotherapy,
and may have vasomotor symptoms due to tamoxifen therapy, estrogen
therapy should not be prescribed.
In a study called the HABITS trial, 434 women with breast cancer
were randomly assigned to receive two years of HRT (estrogen alone
or with progestin depending upon hysterectomy status) or no hormones.
After 2 years of follow-up, women in the estrogen groups were at
least three times more likely to have a recurrence than women who
did not take hormones. Based upon the excessive risk in the hormone
group, the study was terminated in December 2003.
WHERE TO GET MORE INFORMATION — A
doctor is the best resource for finding out important information
related to your particular case. Not all patients are alike, and
it is important that your situation is evaluated by someone who
knows you as a whole person.
BIRTH
CONTROL
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care.
Contraception or birth control is the use of a medication, device,
or method to prevent pregnancy. Such devices or techniques, known
as contraceptives, can work in a number of ways:
Blocking ovulation, the release of eggs from a woman's ovary
Preventing
sperm from getting into the uterus and fallopian tubes (where
fertilization of the egg by the sperm normally occurs)
Preventing
implantation of the embryo (fertilized egg) into the uterine
lining (endometrium)
Most women of reproductive age in the
United States use some form of contraception. However, unintended
pregnancy is still a common problem in this country. As an example,
according to a survey on fertility conducted in 1995, family
planning, and women's health, almost one-third of births in the
previous five years were unintended. More specifically, 22 percent
were said to be "mistimed," whereas
9 percent were "unwanted."
The apparent failure of contraception may result from several
factors, including improper use, failure to follow treatment recommendations
(noncompliance), or failure of the medication, device, or method
itself. Thus, learning about available contraceptive techniques,
understanding which factors should be considered in your decision-making,
and receiving guidance from your doctor or clinic are essential
in determining the method(s) that may be most appropriate and effective
for your specific family planning and reproductive health needs.
Certain contraceptives, such as intrauterine devices (IUDs) and
injectable contraceptives are consistently associated with a low
pregnancy rate. This is because compliance (using the method correctly
or taking the medication on a regular basis) is not a major factor.
Oral contraceptives, or "birth control pills",
are associated with a low pregnancy rate if they are taken properly
(ie, no missed pills). However, studies indicate that the actual
pregnancy rate is much higher because many women do not take the
pill every day as directed.
Other contraceptive methods such as the
condom, diaphragm/cervical cap, and spermicides can be very effective
if used properly. However, these methods are also associated
with higher "actual" pregnancy
rates because of not using the method consistently or properly.
Overall, contraceptive methods that are
specifically designed for use during intercourse and require
decisions shortly before or at that time (eg, the condom, diaphragm)
are generally less effective than "longer-term" contraceptive
methods (eg, intrauterine device, oral contraceptives).
Hormonal contraceptives including pills, skin patches and
vaginal rings
Injectable contraceptives
Barrier methods
Intrauterine devices (IUDs)
Sterilization
Periodic abstinence
Withdrawal (coitus interruptus)
Oral contraceptives — Oral
contraceptives, also referred to as "the pill," in general
contain a combination of the female hormones estrogen and progestin
(a progesterone-like medication). Other examples of hormonal contraceptives
are those that are injectable (into the muscle) or released gradually
from an intrauterine device.
A combined oral contraceptive contains both estrogen and progestin.
A list of available pills is shown in Table 2. Some pills contain
just a progestin, but these are not prescribed as often, because
they are not quite as effective as the combined pills. The combined
pill reduces the risk of pregnancy by:
Preventing ovulation
Keeping the mucus in the cervix thick
and impenetrable to sperm
Preventing implantation of a fertilized
egg in the uterine lining
Other benefits Other
non-contraceptive benefits of the pill include a reduction in:
Menstrual cramps or pain (dysmenorrhea)
Ovarian cancer
Cancer of the endometrium (uterine lining)
Pelvic inflammatory
disease (PID) (infection of the fallopian tubes)
Iron-deficiency
anemia (a low blood count due to low iron levels)
Nausea, breast tenderness, bloating, and mood changes. These
early side effects typically go away after several months.
Breakthrough
bleeding or "spotting" at the wrong time
of the pill pack. This is particularly common during the first
few months of taking oral contraceptives. In addition, missed
pills can result in breakthrough bleeding.
Complications When "the
pill" was first introduced in the 1960s, the doses of both
estrogen and progestin were quite high. Because of the high doses
used, cardiovascular complications occurred, such as high blood
pressure, heart attacks, strokes, and blood clots in the legs and
lungs. However, reductions in both progestin and estrogen doses
in the currently available oral contraceptives have led to a decrease
in these complications. Therefore, oral contraceptives are now
considered a reliable and safe option for almost all women, with
the exceptions noted below.
The majority of studies suggest that taking (or having taken)
the pill does not increase one's risk of breast cancer. However,
there is some concern that women who carry the BRCA1 gene might
have some further increase in risk if they take oral contraceptives.
It has been estimated that the risk for death associated with
use of oral contraceptive pills by nonsmoking women is 1 in 100,000
pill users, versus 1 in 6000 automobile drivers, and 1 in 10,000
women who carry a pregnancy to term. Women taking hormonal contraceptives
should call their health care provider if they experience abdominal
pain, chest pain, severe headaches, eye problems, or severe leg
pain as these could be symptoms of several serious conditions including
heart attack, blood clot, stroke, liver, and gallbladder disease.
Who should not take the pill? Women
who fall into the following categories should NOT take the pill
(ie, the pill is contraindicated) because of an increased risk
of complications:
Aged 35 or over who smoke cigarettes (very high risk for cardiovascular
complications)
Are pregnant
Have had blood clots or a stroke in the past,
because these women are more likely to have blood clots while
taking the pill
Have a history of an estrogen-dependent tumor
(eg, breast or uterine cancer)
Have abnormal, or unexplained
menstrual bleeding (the cause of the bleeding should be investigated
before starting the pill)
Have active liver disease (the pill could worsen the liver
disease)
Have abnormally high blood levels of triglycerides (a
type of cholesterol which can be further elevated by the pill).
Women with high blood pressure might experience a further
increase in blood pressure. Therefore, they should be seen by
their doctor more frequently while on the pill.
Women who take
medication for seizures (epilepsy) might not get the same contraceptive
benefit from the pill as other women because the seizure medicines
change the way the pill is metabolized.
Women with migraine
headaches associated with visual symptoms or other neurological
symptoms should not use the pill.
Women with diabetes mellitus
who are on the pill might need a slightly higher dose of insulin
or oral diabetes medication. Therefore, they need to be seen
on a regular basis once they start the pill.
How do I start the pill? Ideally,
the pill should be started on the first day of the period to provide
the maximum contraceptive effect in the first cycle. However, most
women start their pill on the first Sunday after the period starts
(because most pill packs are arranged for a Sunday start). Some
form of back-up contraception is needed for the first month if
one chooses the Sunday start, because the full contraceptive effect
might not be provided in the first pill pack.
When can I expect my period? The
pill is taken on a 28-day cycle with 21 days of hormone pills followed
by 7 days of placebo pills ("sugar pills"). It is not
necessary to take the placebo pills, but some women find it easier
to remember to start their next pill pack if they have taken the
placebos. The period should occur during the fourth week of the
pill pack, ie, the "placebo week." However, some women
may experience breakthrough bleeding in the first few months. This
almost always resolves without any intervention.
Continuous pill A
newer preparation is available where hormone pills are taken every
day for 12 weeks, followed by placebo pills for 7 days. This results
in only 4 periods per year (although many women experience breakthrough
bleeding when they start). The convenience of this preparation
has appeal to many women. Similar "continuous" regimens
have been used in the past for problems such as endometriosis.
The long-term safety of the continuous pill is not yet established.
Injectable contraceptives The
only injectable contraceptive currently available in the United
States is medroxyprogesterone
acetate or DMPA (Depo-Provera®). DMPA is injected deep
into muscle, such as that of the buttock or upper arm, once every
three months. A preparation that is given subcutaneously (under
the skin) rather than into the muscle, will be available sometime
in 2005.
DMPA alters the cervical mucus and endometrium, making the cervix
impenetrable to sperm and preventing implantation of a fertilized
egg. It also helps prevent ovulation, but not as reliably as the
pill.
In about 90 percent of women who receive DMPA, the cervical mucus
becomes impenetrable to sperm within 24 hours following initial
injection. In the remaining 10 percent, however, the cervical mucus
remains penetrable to sperm for up to seven days. Therefore, women
who receive their initial DMPA injection following the seventh
day of their menstrual period are advised to use a second form
of contraception for seven days.
Other benefits Additional
benefits of DMPA include a decreased risk of:
Endometrial (uterine) cancer
Pelvic inflammatory disease (PID).
Side effects The
most common side effects of DMPA are:
Irregular, prolonged bleeding and spotting, particularly during
early therapy
Absence of menstrual periods (amenorrhea) in up
to 50 percent of women after one year
Weight gain
Women may also have some additional side effects, such as acne,
depression, and headaches. Those who experience such side effects
should speak with their physicians to discuss possible symptom
management and/or proper contraceptive alternatives.
In women who receive injectable progestin alone, there is no
apparent increase in the risk of cardiovascular complications or
cancer. However, there may be an increased risk of osteoporosis.
Because DMPA is long-acting, this method of contraception may
not be ideal for women who wish to become pregnant shortly after
stopping the medication. Although most women are able to conceive
within 10 months, fertility may not return for as long as 18 months
after the last injection.
There are a number of women who prefer to take DMPA as opposed
to the pill, including those who:
Find it difficult to remember to take a pill every day
Are
done with childbearing
Choose not to take the pill because they
are also on seizure medications (the effectiveness of DMPA
is not altered by these medications).
Transdermal contraceptives (skin patches) — Transdermal
contraceptive patches containing both an estrogen and a progestin
have been shown to be as effective oral contraceptives, and one,
Ortho Evra, has been FDA approved. Some women may prefer a skin
patch over a pill. Risks are similar to those with oral contraceptive
pills.
Vaginal rings — A
vaginal ring (Nuvaring) that releases an estrogen and a progestin
that is absorbed into the body through the vaginal mucosa is
available and is worn for three weeks followed by one week off
(during which time a period occurs).
Contraceptive implants — No
contraceptive implants are currently available in the United States
, although one has been FDA-approved (Jadelle). Two implants (Jadelle
and Implanon) are available in most other countries.
Barrier methods — This
type of contraceptive physically blocks or otherwise prevents sperm
from entering the uterus and reaching the egg for fertilization.
Barrier contraceptives include the condom, diaphragm, and cervical
cap. These contraceptive methods:
Have fewer side effects than hormonal contraceptives
Offer
effective protection against certain sexually transmitted diseases
(STDs)
May be available without a prescription (condom and spermicides)
Spermicides (contraceptive creams or gels), are chemical substances
destructive to sperm. They are also available over the counter
and are typically recommended in combination with barrier contraceptives
(to help maximize the contraceptive effect).
Condom The
condom is a relatively thin, flexible sheath, or cover, placed
over the penis to prevent semen from entering the vagina during
sexual intercourse. To help ensure optimal effectiveness and protection,
partners who choose to use condoms must read and follow all manufacturer's
instructions carefully. In addition, as mentioned above, a spermicide
may help to increase the effectiveness of condom use.
When used properly, in addition to preventing pregnancy, condoms
may offer protection to both partners against STDs and infection
with human immunodeficiency virus (HIV). Studies have found the
following:
There is a decreased risk of gonorrhea and other sexually
transmitted diseases in women who consistently use condoms.
In
a study of HIV-negative women whose only risk for infection
was a stable heterosexual relationship with an HIV-infected partner,
none of the women who consistently used condoms became infected.
Regular
use of latex condoms appears to decrease the risk of HIV infection
by about 69 percent. Evidence suggests that other types of
condoms may be less effective than latex condoms in preventing
HIV transmission.
Those who choose to use condoms should also note that petroleum-based
lubricants may actually degrade the condom, decreasing its effectiveness
in preventing infection. Water-based lubricants are considered
safer.
Synthetic condoms are available, but are currently approved by
the FDA only for people who are allergic to latex.
Diaphragm/cervical
cap The
diaphragm and cervical cap fit over the cervix, preventing sperm
from entering the uterus. These devices are available in multiple
sizes and require fitting by a trained clinician, who can also
explain how to insert them properly. It is essential to realize
that these devices must be:
Used with an appropriate contraceptive cream or jelly containing
spermicides
Left in place for six to eight hours after sexual
intercourse. The diaphragm must be removed after this period.
However, the cervical cap can remain in place for up to 24
hours.
Due to these factors, many women may find such contraceptive
methods less desirable than other available options.
The diaphragm and cervical cap are associated with a decreased
risk of certain sexually transmitted diseases and infections, including
gonorrhea, chlamydia, and pelvic inflammatory disease. Much of
the protective effect is thought to be due to the simultaneous
use of spermicides. However, the effectiveness of these contraceptive
methods is less consistent than condoms in preventing the spread
of HIV infection.
Cervical caps are available in latex (the Prentif cap) or silicone
rubber (FemCap). The latter has a strap to facilitate removal and
comes in three sizes.
Intrauterine devices (IUDs) IUDs
are devices that are inserted by a physician into the uterus through
the vagina and cervix. Most are made of molded plastic and include
an attached plastic string that projects through the cervix into
the vagina, enabling a woman to check that the device remains in
place. (If a woman cannot locate the string, she should use another
method of contraception until she is examined by a physician to
determine whether the IUD is still in place.)
The currently available IUDs are safe and effective methods of
contraception. These devices include:
Copper-containing IUDs. These appear to prevent pregnancy
by inducing an inflammatory reaction within the endometrium,
thereby keeping sperm from reaching the fallopian tubes. Copper-containing
IUDs remain effective for approximately 8 to 10 years.
Levonorgestrel-releasing
IUDs. This IUD decreases menstrual blood loss by 40 to 50 percent
and decreases pain associated with periods. Although highly
effective, some women discontinue it because of complete cessation
of menstrual bleeding.
Reports indicate that these IUDs do not have an adverse effect
on fertility after they have been removed. In addition, for women
using copper-releasing IUDs, there is a lower risk of ectopic pregnancy
(or a pregnancy that develops outside the uterus) as compared with
women who do not use contraceptives. However, use of progesterone-releasing
IUDs increases the risk of ectopic pregnancy relative to women
not using any contraceptive. Therefore, if a woman with an IUD
becomes pregnant, it is essential that the site of the pregnancy
be determined immediately.
The frequency of pelvic inflammatory disease is not increased
in women with IUDs who have a low risk for sexually transmitted
diseases (STDs). However, an IUD is not an ideal choice for women
who have a high risk of STDs (ie, women with multiple sexual partners).
Screening for the presence of STDs is recommended before IUD insertion.
In addition, IUDs should not be used (are contraindicated) for
women who have:
A high risk of infections, including women with acquired immunodeficiency
syndrome (AIDS) and a history of intravenous drug abuse. However,
in some selected cases, HIV-infected women who are reliable about
seeing their health care providers may be appropriate candidates.
A high risk of inflammation or infection of the heart valves (bacterial endocarditis)
Fibroids or benign tumors of the uterus that change the shape or size of the
uterine cavity
Sterilization Sterilization
refers to a procedure that renders an individual sterile, or unable
to reproduce. These methods, including tubal ligation and vasectomy,
are the most effective form of contraception. Although these procedures
may be reversible and subsequent operations may restore fertility,
sterilization should always be considered permanent. Therefore,
such procedures should only be performed after careful discussions
with your physician and other members of your healthcare team.
Tubal ligation Tubal
ligation refers to sterilization procedures for women during which
the fallopian tubes may be blocked, cut, or sealed to prevent conception.
Such procedures may be performed on an outpatient basis or for
women in the hospital who have just delivered a baby (postpartum).
The procedure involves a small incision made in the abdominal wall
(laparoscopy) in the operating room while the woman is asleep (under
general anesthesia).
Potential benefits and risks may vary, depending upon the specific
procedure used and other factors. Therefore, it is essential that
women speak with their physicians concerning the most appropriate
choice for their particular situation.
Pregnancy is uncommon after tubal ligation, with the risk appearing
to be related to the woman's age and the type of procedure. When
pregnancy does occur, there is an increased risk that it will be
an ectopic pregnancy.
A new procedure called Essure is available for permanent birth
control. A tiny coil mechanism is inserted into the fallopian tube
using a hysteroscope (a device inserted into the vagina, and through
the cervix to directly visualize the uterus) under local anesthesia.
Vasectomy Vasectomy
refers to a sterilization procedure for men that consists of cutting
or blocking the vas deferens, the tubes that carry sperm from the
testes. This is considered a safe, highly effective surgical procedure
that can be performed under local anesthesia. However, as with
any surgery, it is important to note that it is not completely
free of complications. In some cases, for example, the operation
may need to be repeated. Following surgery, other forms of contraception
must be used for approximately three to six months, until a semen
analysis (semen sample that is then analyzed in the laboratory)
confirms the absence of sperm.
As mentioned above, men who are considering vasectomy should
consider sterilization permanent. However, from 50 to 70 percent
of those in whom the operation is reversed are fertile. The success
rate may depend on the length of time between vasectomy and the
reversal procedure. Generally, the longer after vasectomy, the
lower the chance of a return of normal fertility.
There had been concern that the risk of testicular and prostate
cancer may be increased in men who have had a vasectomy, but this
does not appear to be the case.
Other methods Some
women and their partners may not be able to consider the contraceptive
methods mentioned above due to religious or other reasons. In such
cases, appropriate options may include periodic abstinence or withdrawal.
Periodic abstinence Periodic
abstinence involves attempting to predict the specific time of
the month when a woman is fertile and refraining from sexual intercourse
during that time. Different methods may be used to help determine
the fertile period:
Rhythm or calendar method, which is based upon the date of the
last menstrual period. Women using the rhythm or calendar method
should determine the first day of the fertile period by subtracting
18 days from their shortest menstrual cycle (eg, based on their
previous 12 cycles). They may calculate the last day of the fertile
period by subtracting 11 days from their longest cycle. As an example,
if a woman's menstrual cycle varies from 28 to 30 days, she should
refrain from intercourse from days 10 to 19 of each cycle. (Day
1 refers to the first day of her menstrual period.) It is essential
to note that this method is not appropriate for women who have
irregular cycle lengths.
Ovulation method, which is based upon changes in temperature or observing cervical
mucus. Regular measurement of body temperature first thing in the morning before
getting out of bed (basal body temperature) reflects progesterone-induced changes
in temperature around the time of ovulation, with basal temperature rising
slightly (about 0.5 degrees F) after release of the egg. With this technique,
the woman takes her temperature every morning immediately upon awakening using
a special basal body thermometer that is available in drug stores. Women should
refrain from intercourse from the cessation of her menstrual period until three
days after a rise in basal temperature is recorded.
Characteristics of cervical mucus vary at different times of
the menstrual cycle. During ovulation, the mucus is typically secreted
in more abundant amounts and tends to become more watery. Using
this method, women should refrain from intercourse when this watery
cervical mucus first appears until three to four days after the
greatest amount of mucus production.
The specific time of ovulation may also be determined using commercially
available ovulation kits. However, this method may be quite expensive.
When used perfectly, ovulation methods are generally more effective
than the calendar or rhythm method, with estimated failure rates
of approximately 3 versus 9 percent. However, for those who do
not correctly use ovulation methods, failure rates may be as high
as 86 percent (with a 28 percent risk of pregnancy per cycle).
Withdrawal Also
known as coitus interruptus, the withdrawal method requires the
man to withdraw from the vagina before ejaculation, when sperm
is released in the semen during orgasm. Conception may occur if
withdrawal is not timed appropriately or if sperm is released before
orgasm (eg, within preejaculatory fluid). With this method, contraceptive
failure rates may be as high as 18 to 20 percent.
Lactation Breastfeeding
or the production and secretion of breast milk after childbirth
(lactation) has limited effectiveness and reliability in preventing
pregnancy. However, in women who breastfeed, there is known to
be a delay in the resumption of ovulation. As an example, from
88 to 89 percent of women who breastfeed full-time do not ovulate
for up to six months after childbirth (postpartum). Women who breastfeed
full-time and do not menstruate are more than 98 percent protected
from pregnancy for the first six months. However, women who use
supplemental feeding and those who menstruate are more likely to
ovulate.
Experts suggest that it is probably safest to resume the use
of contraceptives in the third month following childbirth for those
who breastfeed full-time and in the third week postpartum for those
who do not breastfeed or do so infrequently. Women should speak
with their physicians concerning the appropriate timing and the
most appropriate form of contraceptive use following childbirth.
WHERE TO GET MORE INFORMATION As
discussed above, it is important to speak with a physicians and
other members of your healthcare team to help determine the contraceptive
method(s) that will most appropriately and effectively fulfill
your specific family planning and reproductive health needs. Some
women also find it helpful to speak with counselors at local health
clinics and centers. In addition, to help ensure optimal effectiveness
of the contraceptive method(s) you have selected, it is essential
that you follow your physician's as well as the product manufacturer's
recommendations (such as provided on packet inserts). If you are
concerned about or are having difficulty with certain contraceptive
methods (eg, having trouble remembering to take birth control pills),
a doctor may provide you with additional guidelines or may recommend
using another appropriate form of birth control. Because every
patient is different, it is important that your situation is evaluated
by someone who knows you as a whole person.
The
major goal of prenatal care is to ensure the birth of a healthy
baby with minimal risk for the mother. There are several components
involved in achieving this objective:
Evaluation of the health status of both mother and fetus
Early,
accurate estimation of the gestational age
Identification of
the patient at risk for complications
Anticipation and prevention,
if possible, of problems before they occur
Patient education
and communication
Observational studies have shown that women who receive antenatal
care have lower maternal and perinatal mortality and better pregnancy
outcomes. However, the optimal components of prenatal care have
not been rigorously examined in well-designed studies. Furthermore,
comparison of pregnancy outcome in women who received and did not
receive prenatal care is usually confounded by socioeconomic factors
that influence access to care and maternal/perinatal outcome.
In the United States in 2003, 84.1 percent of pregnant women
obtained prenatal care in the first trimester, and only 3.5 percent
received no care or initiated prenatal care in the third trimester.
Suspected
pregnancy should be confirmed. The earliest signs and symptoms
of pregnancy include: absence of expected menses, breast fullness
and tenderness, urinary frequency, nausea, and fatigue. The "gold
standard" for diagnosis of pregnancy is the detection of the
beta subunit of human chorionic gonadotropin (hCG) in blood or
urine using immunologic techniques. The most sensitive enzyme-linked
immunosorbent assays (ELISA) can detect hCG approximately one week
after fertilization, a hormone produced almost exclusively during
pregnancy. The hCG concentration doubles every 29 to 53 hours during
the first 30 days after conception in a viable, intrauterine pregnancy.
Serum hCG reaches peak concentrations of 100,000 IU/L (in relation
to the First International Reference Preparation) at 8 to 10 weeks
after the last menstrual period. The concentrations start to decrease
after week 12 and stay fairly constant at approximately 30,000
IU/L from about the 20th week until term.
It
is important to identify patients at increased risk of maternal
medical complications, pregnancy complications, or fetal abnormalities.
Ideally, this is accomplished prior to pregnancy during a preconception
consultation. Early identification of women at higher risk for
adverse outcomes allows the provider to educate the patient and
intervene to minimize the chance of a poor outcome.
History At
or prior to the first prenatal visit, the patient should complete
a questionnaire detailing her social, medical, and family history.
This information can be used to start an obstetric record that
will record her prenatal, intrapartum, and postpartum course.
Several paper and computerized obstetric record forms are commercially
available for this purpose. They ensure complete and systematic
documentation of the pregnancy and often may be used for risk-assessment
planning. The elements of the patient history include:
Personal and demographic information
Past obstetrical history
Personal and family medical history
Genetic history
Menstrual history
Current pregnancy history
The American College of Obstetricians and Gynecologists (ACOG)
and the American Medical Association (AMA) guidelines on domestic
violence recommend that physicians routinely assess all pregnant
women for domestic violence.
A tentative estimated date of delivery or confinement (EDC) can
be calculated from the menstrual history, or, if appropriate, based
upon the results of the physical examination or ultrasound examination.
EDC is calculated by adding seven days to the last menstrual period
date and then subtracting three months in women with 28 day cycles.
After obtaining a complete history, a "problem list" should
be generated. These lists are very useful for preventing the inadvertent
omission of necessary monitoring and interventions. Unfortunately,
risk-assessment tools for the prediction and prevention of preterm
birth have had limited success.
Physical examination
The focus
of the complete physical examination is the assessment of the
pelvis, including uterine shape and size, clinical pelvimetry,
and estimation of gestational age. If there is uncertainty regarding
the gestational age, then first trimester or early second trimester
ultrasonography can establish an EDC. Ultrasound measurement of
the crown–rump
length at 7 to 14 weeks of gestation is the most accurate technique
for estimation of gestational age; it is accurate to within three
to five days, with 95 percent certainty. In a viable pregnancy,
the fetal heart usually can be heard by 9 to 12 weeks of gestation
using a Doppler instrument. Transvaginal ultrasound can determine
fetal viability as early as 5.5 to 6.5 weeks.
Routine A
standard panel of laboratory tests should be obtained on every
pregnant woman at the first prenatal visit. This panel can be
augmented by additional testing of women at risk for specific
conditions. Of note, the Centers for Disease Control recommend
chlamydia screening for all pregnant women, whereas the Guidelines
for Perinatal Care recommend testing only women at high risk.
Human immunodeficiency
virus ACOG supports universal HIV testing
of pregnant women. Advantages of universal testing include:
The risk of perinatal transmission can be reduced from 15
to 40 percent in the absence of any intervention to less than
2 percent with antiretroviral therapy and avoidance of breastfeeding
and labor.
An informed decision can be made about continuing the
pregnancy
Appropriate medical management of the woman herself
can be initiated
Prevention of transmission to and/or identification
of infected partners
At-risk women Additional
laboratory tests commonly performed in at-risk individuals include:
Gonorrhea
Tuberculosis
Red cell indices to screen for thalassemia
(eg, MCV <80)
Hemoglobin electrophoresis to detect hemoglobinopathies (eg,
sickle cell, thalassemias)
Hexosaminidase A for Tay Sachs screening (serum test in nonpregnant
and leukocyte assay in pregnant individuals) and DNA analysis
for Canavan disease
Cystic fibrosis carrier testing
Serum phenylalanine level
Toxoplasmosis screen
Hepatitis C antibodies
Neurologic development may be adversely affected in children
born to mothers with hypothyroidism, while maternal hyperthyroidism
can lead to fetal and maternal complications. The American College
of Obstetricians and Gynecologists recommends that thyroid function
be assessed in women with a history of a thyroid disorder or with
symptoms of thyroid disease (other than an isolated, slightly enlarged
thyroid gland). A clinical consensus group (comprising representatives
from the Endocrine Society, American Thyroid Association, and American
Association of Clinical Endocrinologists) concluded that there
is insufficient evidence to recommend for or against routine screening
of thyroid function in pregnant women or those hoping to become
pregnant.
The health care provider should discuss the interpretation of
test results and options for further evaluation. If a disorder
is diagnosed, then the natural history of the disorder, risk of
disease in offspring, and the woman's reproductive options should
be discussed. An abnormal result is often an indication for referral
for genetic counseling.
Testing for sexually transmitted diseases (eg, HIV, syphilis,
hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated
in the third trimester in any woman at high risk for acquiring
these infections; all women under age 25 years should be retested
for Chlamydia trachomatis late in pregnancy.
PATIENT EDUCATION
General issues The
first prenatal visit is a good time to discuss the patient's responsibilities
and the expected course of pregnancy and delivery. This information
can be provided by the physician, as well as by ancillary staff
and through written patient handouts. Some of the information should
be repeated when the issues become more germane over the course
of pregnancy.
Patients can be given information regarding the general plan
of management for the pregnancy:
Number and frequency of prenatal visits
Recommendations for
nutrition, weight gain, exercise, rest, and sexual activity
(see below)
Toxoplasmosis precautions (eg, hand washing, eating habits,
cat care)
Abstinence from alcohol, cigarettes, illicit drugs
Information on the safety of commonly used nonprescription
drugs
Recommendation to continue wearing 3-point seat belts during
pregnancy. The lap belt is placed across the hips and below
the uterus; the shoulder belt goes between the breasts and
lateral to the uterus.
Potential problems related to plans for
travel, work outside of the home, or hobbies (see below)
How
to reach the provider after business hours, coverage arrangements,
and the role of office personnel (eg, nurses, midwives)
Signs
and symptoms to be reported to the health care provider should
be discussed at each visit, as appropriate for gestational
age (eg, vaginal bleeding, ruptured membranes, contractions,
decreased fetal activity)
Questions about labor, hospitalization,
mode of delivery, and analgesia and anesthesia can be addressed
in general terms at the initial visit and discussed in greater
detail later in pregnancy.
Childbirth classes and breastfeeding
recommendations
Patients who have problems with substance abuse should be strongly
advised of the risks of this behavior and referred to cessation
programs in their area. All patients should be encouraged to contact
their provider with any concerns and before taking any drugs (prescription,
over the counter, or herbal [alternative] remedies) that were not
previously approved.
The patient's expectations should be oriented to the course of
the average pregnancy. This includes a discussion of the rates
of congenital anomalies, cesarean delivery, and hospitalization.
In addition, a more detailed discussion of the management plan
should be communicated with women who are at risk for pregnancy
complications because of a maternal disorder or prior adverse pregnancy
outcome.
Specific pregnancy issues and complications are discussed in
detail separately.
Nutrition, vitamins, and weight gain All
pregnant women should be encouraged to eat a well-balanced diet.
In addition, the Centers for Disease Control and Prevention (CDC)
and the American College of Obstetricians and Gynecologists (ACOG)
have recommended supplemental folic acid (400 mcg) in the preconceptional
and early prenatal period to prevent neural tube defects (NTDs).
A standard prenatal multivitamin satisfies the requirements of
most pregnant women.
Although there are few, if any, well-designed
studies regarding nutrition in pregnancy, the relationship between
maternal prepregnancy weight, weight gain during pregnancy, and
newborn weight is well known. For this reason, nutritional recommendations
for pregnant women are based upon the prepregnancy body mass
index (BMI). For optimal outcome, the Institute of Medicine advises
a weight gain of 12.5 to 18 kg (28 to 40 lb) for underweight
women (BMI<19.8),
7 to 11.5 kg (15 to 25 lb) for overweight women (BMI26),
and 11.5 to 16 kg (25 to 35 lb) for women of average weight (BMI
19.8 to 26.0). This can be achieved with an additional 300 Kcal
per day for average weight women.
Foods to limit or avoid It
has been recommended that pregnant women limit quantities or avoid
some foods during pregnancy.
Fish The
quantity and type of fish consumed should be regulated and certain
types of fish should be avoided during pregnancy due to concerns
about possible teratogenic effects from environmental toxins, such
as mercury. Only cooked fish should be eaten.
Caffeine Daily
caffeine intake greater than 500 mg appears to double the risk of spontaneous
abortion and excess coffee consumption may increase the risk of stillbirth. There
may also be a small decrease in birth weight (28 g per 100 mg caffeine) with
high caffeine intake. Therefore, restriction of caffeine consumption should be
considered.
Excessive
vitamin/mineral intake Excessive intake of vitamin A (greater than 10,000
IU per day) may be harmful to proper fetal development and should be avoided.
Excessive quantities of iodine can cause fetal goiter and intake of large amounts
of vitamins D, E, and K may also be toxic.
Antigen
avoidance diets Some research has suggested that prescribing an antigen
avoidance diet to pregnant women may decrease the incidence of atopic disease,
including asthma, in their infants. However, a review of three trials involving
504 women did not show a substantial reduction of atopy in offspring. In particular,
there is inadequate evidence that sensitization to peanuts in the maternal diet
occurs and contributes to the occurrence of peanut allergy in children.
Work A
woman with an uncomplicated pregnancy who is employed where there
are no greater potential hazards than those encountered in routine
daily life may continue to work without interruption until the
onset of labor. However, the physical demands of the woman's
job should be considered, especially in women at higher risk
of preterm delivery. Postpartum, the patient may resume working
four to six weeks after an uncomplicated delivery.
Working during pregnancy should be limited or contraindicated
in some women:
Vaginal bleeding
Short (<3 cm) or dilated cervix before
36 weeks gestation
Uterine malformation
Pregnancy-induced hypertension
Fetal growth restriction
Multiple gestation
Prior history of preterm birth
Excessive Amniotic Fluid (Polyhydramnios)
Maternal medical disorders
that are unstable or associated with impaired placental perfusion
The Pregnancy Discrimination Act requires employers offering
medical disability benefits to treat pregnancy-related disabilities
just like all other disabilities. Pregnant workers must be provided
the same insurance benefits, sick leave, seniority credits, and
reinstatement privileges awarded workers disabled by other causes.
The Occupational Safety and Health Administration (OSHA) sets
and enforces standards requiring employers to provide a workplace
free from recognized hazards likely to cause serious physical harm.
Lead, ethylene oxide, ionizing radiation, and dibromochloropropane
are substances with significant potential for reproductive toxicity.
In addition, pregnant health care workers should minimize exposure
to anesthetic gases, infectious agents, antineoplastic drugs, and
organic solvents. Pregnant women may safely work in operating rooms
equipped with gas scavenging systems and adequate ventilation.
In 1991, the Supreme Court ruled that a rigid policy that banned
women of reproductive age from certain jobs discriminated against
women on the basis of their sex. Although several toxic substances
found in the workplace also could harm men of reproductive age,
men were not banned from jobs on that basis. Therefore, it is illegal
for an employer to ban a woman from certain jobs because she might
become pregnant while working there.
Exercise In
the absence of obstetric or medical complications, a pregnant
woman may engage in a moderate level of physical activity. Exercise
will help a pregnant woman maintain cardiorespiratory and muscular
fitness.
Sexual activity Theoretically,
sexual intercourse may stimulate labor due to physical stimulation
of the lower uterine segment, the body’s release of oxytocin
(hormone produced by the body) as a result of orgasm, direct action
of prostaglandins (another agent produced by the body) in semen,
or increased exposure to infectious agents. However, in the absence
of pregnancy complications (eg, vaginal bleeding, ruptured membranes),
there is insufficient evidence to recommend against sexual intercourse
during pregnancy. Most studies have not shown an increased risk
of preterm labor/delivery or infectious complications (unless a
sexually transmitted disease is acquired).
Airline travel Most
airlines allow women to fly up to 35 to 36 weeks of gestation,
although individual policies may vary. Commercial airline travel
is generally safe for women with uncomplicated pregnancies. There
does not appear to be an increased risk of spontaneous abortion
and fetal heart rate is not affected if the mother and fetus are
healthy.
Because of the changes in heart rate and blood pressure that
take place in pregnancy and the lack of availability of emergency
care, certain precautions should be taken:
Women with complicated pregnancies (eg, sickle cell anemia, high
risk of preterm delivery, preeclampsia) should avoid air travel.
All airline travelers should maintain hydration, periodically move their lower
extremities to avoid stasis and potential venous thrombosis, and continuously
wear seat belts to protect against unexpected turbulence.
Supplemental oxygen should be administered to pregnant women who must travel
and may not tolerate the hypoxic environment of high altitude flying, even
in pressurized aircraft.
The amount of cosmic radiation received during airline travel
is below the level at which there begins to be concern about possible
harmful fetal effects (20 millisievert or 2 rem). As an example,
a woman on a roundtrip transpolar flight from New York to Tokyo
would be exposed to approximately 15 mrem cosmic radiation; for
a roundtrip transcontinental flight across the United States the
exposure would be 6 mrem. By comparison, the recommended limit
for maximum annual radiation exposure is 100 mrem. Pilots, flight
attendants, and frequent fliers might exceed this level. They should
be aware of their personal radiation exposure, which can be calculated
using the Federal Aviation Administration.
Moderate and high altitudes Airplane
passenger cabins are usually pressurized to an altitude of 5000
to 8000 feet (1524 to 2438 meters). The PO2 values at these altitudes
are 132 and 118 mmHg, respectively. Pregnant women may be exposed
to altitudes in this range from other sources, such as visiting
a mountain resort or traveling in a hot air balloon or noncommercial
aircraft. There is scant literature about acute, short-term exposure
of pregnant women to these moderate altitudes. One study evaluated
seven women in the third trimester at sea level (180 feet) and
then within two to four days of visiting a facility at 6000 feet
(1829 m). Plasma glucose rose from 4.53 to 5.51 mmol/L (81.6 to
99.2 mg/dL); however, maternal heart rate, oxygen consumption,
ventilation, tidal volume, and plasma catecholamine and lactate
levels did not change significantly, nor was there a change in
fetal heart rate.
These data and other reports, although limited, are reassuring
that women with uncomplicated pregnancies can tolerate acute exposure
to moderate altitudes. Since an individual's altitude tolerance
cannot be reliably determined at sea level, advice on travel to
intermediate altitudes should err on the side of caution.
Birth defects and genetic issues The
prevalence of birth defects of medical, surgical, or cosmetic significance
is 2 to 4 percent among live born infants and does not vary among
ethnic groups. Both genetic and environmental factors play a role
in their pathogenesis. The clinician should discuss with the patient
the causes of congenital anomalies, assess risk in the individual
patient, review options for and limitations of prenatal diagnosis,
and decide whether additional testing and referral to a geneticist
would be useful.
Overview The
routine examination at each subsequent visit consists of measurement
of blood pressure and weight, measurement of the uterine fundus
to assess fetal growth, auscultation of fetal heart tones, and
determination of fetal presentation and activity. The urine is
typically screened for protein and glucose at each visit, although
the value of the latter is questionable in women who have been
screened for gestational diabetes. When multiagent dipsticks
are used to dipstick urine for glucose/protein, positive results
for other substances (eg, blood, white blood cells, bilirubin)
may be noted incidentally. These should be evaluated as for nonpregnant
individuals.
Repeated screening for asymptomatic urinary tract infections
is not needed in women at low risk for infection (eg, absence of
urinary tract anomalies, preterm labor, or medical conditions predisposing
to urinary infection). These simple, noninvasive, inexpensive procedures
may detect 50 percent of fetuses with growth abnormality, prevent
70 percent of eclampsia, and uncover 80 percent of breech presentations
prior to labor.
The frequency of prenatal visits should be based upon patient
needs; in general, the minimum standard intervals for women with
uncomplicated pregnancies are every four to five weeks until 28
weeks of gestation, every two to three weeks from 28 to 36 weeks,
and then weekly until delivery. This regimen has been questioned
given the cost and time constraints of modern society and lack
of proven efficacy.
More frequent visits may be of benefit in monitoring women with diabetes, hypertension,
threatened preterm birth, post-term pregnancies, and other pregnancy complications.
NTDs and Down syndrome a
blood test to screen for risk of Downs Syndrome is generally done
between 15 and 21 weeks gestational age.
Gestational diabetes a
one hour glucola, in which the patient drinks a glucose drink and
has her blood drawn and glucose levels checked one hour later is
done between 24 and 28 weeks gestational age.
Sexually transmitted
disease As
discussed above, testing for sexually transmitted diseases (eg,
HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea)
should be repeated in the third trimester in any woman at high
risk for acquiring these infections; all women under age 25 years
should be retested for Chlamydia trachomatis late in pregnancy.
Blood count and antibody
screening A
hemoglobin or hematocrit should be repeated early in the third
trimester. Antibody screening is repeated in unsensitized Rh(D)-negative
women and Rh(D) immune globulin administered, as indicated.
GBS All
pregnant women should be screened for group B beta-hemolytic streptococcus
(GBS) colonization with swabs of both the lower vagina and rectum
at 35 to 37 weeks of gestation. The only patients who are excluded
from screening are those with GBS bacteriuria earlier in the current
pregnancy or those who gave birth to a previous infant with invasive
GBS disease. These latter patients are not included in the screening
recommendation because they should receive intrapartum antibiotic
prophylaxis regardless of the colonization status.
Influenza immunization Influenza
vaccination is recommended for women in the second and third
trimesters, and for high-risk women prior to influenza season
regardless of stage of pregnancy.
Fetal assessment Sonographic
and cardiographic fetal assessments are indicated in patients
at-risk for fetal complications.
All pregnant women should seek prenatal care as soon as they recognize
that they are pregnant. Preconceptual counseling is recommended
if a woman is planning on getting pregnant (see Preconceptual Counseling).
For many women, gynecologic and reproductive health care represent
their only regular connection to the medical system. The gynecologic
evaluation can provoke anxiety in both patients and health care
professionals. The provider's proficiency will go a long way in
establishing positive relationships with female patients and providing
them with complete and sensitive care.
Individual women vary tremendously in their knowledge of and
comfort with their own bodies. While some may be quite open in
disclosing their sexual, reproductive, and genital concerns, others
will find such discussions embarrassing or socially inappropriate.
Thus, it is essential that providers maintain a sensitive and nonjudgmental
approach during this encounter.
The most common gynecologic concerns relate to vaginal discharge,
abnormal bleeding, pain, urinary problems, breast disorders, sexual
dysfunction, and infertility. When a patient identifies one of
these issues, detailed questioning can guide further evaluation
and diagnosis.
Normal vaginal discharge is composed of mucous-like cells from
the inner cervix in combination with sloughed off vaginal wall
epithelium and normal bacteria. The volume of discharge varies
considerably among women and timing in the menstrual cycle. Discharge
that is malodorous, burning, pruritic, painful, or bloody requires
investigation.
Bleeding is abnormal when it is associated with a change in the
woman's normal menstrual pattern or it occurs after menopause.
Irregular bleeding occurs commonly during the period right before
menopause and may mask underlying serious pathology.
The characterization of pelvic pain should include the time of
onset, duration, location, quality, and severity. The relationship
of the pain to menstruation, physical activity, or sexual activity
and alleviation of the pain with pain medications, hormonal contraceptives,
or position change are useful components of the pain history. Associated
gastrointestinal or urinary symptoms could point to a nongynecologic
source of the pain.
Urinary incontinence occurs among women of all ages and requires
evaluation when the involuntary loss of urine is severe enough
to affect her lifestyle. Patients who complain of incontinence
should be questioned about urinary tract infections, diuretic use,
volume and timing of fluid intake, history of neurologic disease
or diabetes, and caffeine and alcohol use. A careful voiding and
intake history will help the clinician determine the underlying
cause. Precipitating factors, such as valsalva (bearing down) or
an overwhelming urge to void, can help to differentiate stress
incontinence from detrusor (bladder muscle) instability.
Perimenstrual breast tenderness is due to hormonal stimulation
of the breast and is generally not a cause for concern. However,
evaluation is indicated for the new onset of breast pain, a change
in the usual type of discomfort, or a visible or palpable lesion
in the breast. Examination by a physician is mandatory when a woman
detects a breast mass or bloody nipple discharge. Galactorrhea
(milky breast discharge) can be a sign of an elevated prolactin
level from a pituitary tumor or, more commonly, is due to chronic
breast stimulation.
Many sexual problems result from and/or cause reproductive dysfunction
and gynecologic problems. In one large cohort, 43 percent of surveyed
women reported some type of sexual dysfunction, and poor sexual
function was found to correlate with diminished quality of life.
Many women are reluctant to express concerns regarding these matters,
but welcome the opportunity to discuss them when approached in
an interested and compassionate manner. The provider does not have
to feel personally capable of providing sexual counseling or therapy
to open a discussion. He or she may accomplish a great deal simply
by excluding major medical or psychological sources of the patient's
concerns. A brief set of screening questions is adequate to determine
whether a problem exists that requires further inquiry.
Are you currently having sexual relations?
If so, with men
or women or both?
If not, when did you last engage in sexual
activity?
Are you and your partner satisfied with the frequency
and quality of your sexual experience?
Have you recently had
any new partners or sexual contacts?
If the patient discloses concerns about sexual function, the
provider should ask more detailed questions. The acuity or chronicity
of the problem, specificity to the current relationship, and other
relationship concerns are essential factors. The provider should
inquire about other contributing factors, such as childbirth and
parenting stressors, job or school pressures, financial stress,
medical illness, new medical therapy or medications. Associated
symptoms of pain, dyspareunia (pain during intercourse), depression,
anhedonia (absent sexual desire), or constitutional illness may
help define the problem's source.
Many women become very concerned when they have not conceived
a pregnancy after a few months of trying, while others have had
years of unprotected, regular intercourse without recognizing that
an underlying medical problem may exist. By definition, a couple
is infertile after twelve months of unprotected intercourse without
a spontaneous conception. Before proceeding with an infertility
evaluation, the provider should confirm that the couple is having
regular, frequent intercourse during the middle of the menstrual
cycle. Once the diagnosis is established, the infertility history
should focus on three factors; ovulation, tubal and uterine problems,
and male factors. (“Infertility”)
GYNECOLOGIC EXAMINATION
The gynecologic examination traditionally includes the internal
and external genitalia, pelvic organs, abdomen, and breasts. However,
a more comprehensive examination may be indicated to provide complete
primary care and to evaluate gynecologic problems that involve
other organ systems.
There is no defined age at which the first gynecologic examination
is performed, as this depends upon the probability of identifying
a gynecologic problem.
The first genital inspection should be performed on the newborn.
This will confirm patency of the anus and vagina, and help identify
congenital anomalies and ambiguous genitalia.
Young girls should undergo a focused genital examination when the patient or
parent identifies a gynecologic symptom.
Similarly, a gynecologic examination should be performed on any adolescent
with a genital or pelvic complaint. However, the use of a complete pelvic
examination as a screening tool for sexually active teenagers is somewhat
controversial. Advocates of a full examination cite the potential to identify
sexually transmitted diseases (STDs), visually as well as with laboratory
testing, and the opportunity to initiate cervical cancer screening. Those
against routine examination note a lack of evidence-based guidelines on heath
outcomes and cost effectiveness. They note the availability of urinary screening
for gonorrhea and Chlamydia, the low detection rate of high grade cervical
dysplasia (abnormal papsmear)in teens, and the potential to deter girls from
appropriate health care and counseling if they fear a pelvic examination.
Clinically, the pelvic examination is often linked to cervical
cancer screening. Guidelines advise the first test be performed
within three years of first sexual intercourse or at age 21, whichever
comes first. The age of initiation was advanced given the high
rate of acquisition and clearance of human papilloma virus (HPV)
with the onset of sexual activity. However, in deciding when to
initiate cervical cancer screening, the clinician must consider
the individual patient's risk factors for cervical intraepithelial
neoplasia (early cervical cancer), as well as the reliability of
the sexual history. HPV may be acquired congenitally or through
sexual abuse, which also must be considered.
Sexually active adolescents should be counseled regarding the
benefits of pelvic screening, the importance of responsible, consensual
sexual behavior, and the availability and proper use of effective
contraception. While a full pelvic examination should be offered
and discussed, its proven benefits should be considered against
the potential to deter sexually active girls from counseling and
less invasive screening.
Annual
gynecologic examinations are often linked to cervical cancer screening
and contraceptive care. However, annual screening for cervical
cancer is not recommended for all women. While cervical cancer
screening may be deferred, the American College of Obstetricians
and Gynecologists (ACOG) continues to recommend annual pelvic examinations
for adult women. Furthermore, the Centers for Disease Control and
Prevention recommend STD screening for any woman at risk for exposure.
Any patient with genital or pelvic symptoms should undergo a
thorough gynecologic examination. Unfortunately, there is a lack
of evidence regarding the utility and cost effectiveness of pelvic
screening in asymptomatic patients who do not require cervical
cancer screening or STD screening. Potential benefits of the examination
include the identification of otherwise unrecognized infectious,
neoplastic, or other dermatologic pathology. A routine pelvic examination
has not been established as an effective means of ovarian cancer
detection, and even an examination under anesthesia has been shown
to have limited sensitivity at detecting adnexal masses . The benefits
and indication for pelvic examination should be reviewed with patients
at the time of the annual examination.
The pelvic examination is often used as a prerequisite to obtain
hormonal contraceptives. While the incentive to prevent pregnancy
may motivate sexually active women to obtain an examination, this
requirement may act a barrier to effective pregnancy prevention.
While a full health history and blood pressure check are important
in the provision of hormonal contraception, some argue that this
method may be safely prescribed without a full pelvic examination.
Offering contraception without a pelvic examination may bring women
into the health care system who might otherwise receive limited
care, and provide an opportunity to counsel patients on the value
of full gynecologic care.
The pelvic examination is traditionally performed in the dorsal
lithotomy position in order to allow optimal exposure of the internal
and external genitalia and palpation of the pelvis. Unfortunately,
laying the patient in a horizontal position does not allow eye
contact between the provider and patient, and may increase her
sense of vulnerability. This may also be a physically difficult
position for women with cardiorespiratory or musculoskeletal limitations.
Elevating the head of the table 30 to 90 degrees makes it easier
for the woman to relax, thereby facilitating bimanual examination.
It is widely recognized that a pelvic examination may be uncomfortable.
In one study, approximately 1000 women in a variety of clinical
settings were asked to explain the parts of the examination that
were uncomfortable, the reasons for the discomfort, and to suggest
ways the physician could have improved the process. Physical discomfort
(37 percent), embarrassment (20 percent), disliking the attitude
of the examiner (7 percent), and experiencing problems during a
previous examination (5 percent) were the major concerns reported.
Techniques suggested to improve the examination process included
explaining each step of the examination in advance, providing more
information about the reproductive organs, warming the instruments,
and increased gentleness. Other surveys have recommended that physicians
make an effort to maintain eye contact during the examination and
give the patient choices where possible.
In rare cases the gynecologic examination may not be possible
in the office setting. Examples include severe physical limitations,
patient intolerance due to pain or anxiety, or examination of small
children. In such cases the examination may need to be performed
with conscious sedation or general anesthesia. .
For some women a pelvic examination may provoke memories of prior
painful examinations, or even physical or sexual abuse. For such
patients the exam may be nearly unbearable, and may deter the patient
from seeking appropriate health care. Such anxiety may manifest
as tense and withdrawn body language, extreme discomfort with the
examination, or refusal to have an examination at all.
At first recognition of the patient's discomfort the provider
should stop the physical examination and address the patient's
concerns. If it becomes clear that the patient has been abused
or is suffering from severe anxiety, the provider may need to delay
the examination in order to elicit help from a therapist or social
worker. Often by discussing the examination ahead of time and agreeing
to stop uncomfortable procedures at the patient's request, the
provider can give the woman some control over the situation, which
may alleviate some of her anxiety regarding the examination. Importantly,
the provider should never proceed in the setting of patient refusal,
no matter how medically necessary he or she perceives the examination.
A patient's consent to the gynecologic exam is often assumed,
although patients have expressed greater satisfaction when their
permission is explicitly requested. Adolescents may undergo a pelvic
examination without their parents' knowledge or permission if the
examination is performed in the context of a sexual or contraceptive
concern. On the other hand, parental consent is required for childhood
examinations and pelvic examinations unrelated to sexual contact.
Permission from a legal guardian is required for a nonemergent
pelvic examination of a patient who cannot consent to her own health
care.
An annual clinical breast examination for women over 40 years
old is recommended by ACOG and the American Cancer Society. Even
with younger women, the exam offers an opportunity to demonstrate
the technique of breast self-examination and to encourage women
to perform this examination on a regular basis.
The vagina is first inspected using an appropriately sized, wet
or lightly lubricated speculum. However, lubricants other than
plain water should be avoided if cervical cytology is to be obtained.
Atraumatic insertion is aided by helping the muscles at the opening
of the vagina to relax. This may be accomplished by inserting a
finger into the distal vagina and gently apply downward pressure.
The speculum is then inserted and downward pressure applied. The
speculum is advanced in a direction free of resistance and opened
as the apex of the vagina is reached.
If abnormal discharge is identified it should be evaluated for
volume, color, consistency, and odor. The pH of normal discharge
is less than Cervical cancer screening, if required, can be performed
by a variety of techniques. In general, the cervical cytology should
be obtained before wiping away any cervical discharge or performing
cervical cultures.
The degree of vaginal wall relaxation and uterine prolapse is
evaluated by removing the top blade of the speculum and using the
posterior blade as a retractor. It is helpful to ask the patient
to bear down to determine the degree of uterovaginal descensus.
The vagina, cervix, uterus, adnexa, and cul-de-sac are palpated
after the speculum examination, so that the glove lubricant will
not interfere with cultures or cytologic samples. The index and
middle fingers of the dominant hand are normally used to examine
the vagina and uterus, although some physicians find that switching
hands during the examination facilitates evaluation of the adnexae.
Only a single finger can be inserted comfortably in patients with
a narrow introitus or small vaginal orifice. The abdominal hand
should be used to sweep the pelvic organs downward, while the vaginal
hand is simultaneously elevating them. It should only take a moment
to determine the size, shape, symmetry, mobility, position, and
consistency of the uterus.
The adnexal areas(areas where the ovaries normally lie) are checked
for the presence of appropriately sized, mobile ovaries (eg, about
2 by 3 cm), which are normally somewhat tender. However, ovaries
that can be felt in postmenopausal women are not normal and require
investigation.
The final component of the gynecologic assessment is the rectovaginal
examination. This allows optimal palpation of the cul-de-sac and
uterosacral ligaments, as well as the uterus and adnexae. Evaluation
for rectal tumors, hemorrhoids, and occult blood can also be performed.
A yearly well woman evaluation includes a thorough examination
and even if a papsmear is not indicated, it is important that every
woman have a yearly well woman examination.
CHRONIC
PELVIC PAIN
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care
Chronic pelvic pain is pain that occurs below the umbilicus (or
belly button) that lasts for at least six months. It may or may
not be associated with menstruation. Chronic pelvic pain is not
a disease, rather, it is a symptom that may be caused by several
different conditions.
Some
of the gynecologic causes of pelvic pain include:
Endometriosis The tissue lining
the inside of the uterus is called the endometrium. Endometriosis
is a condition in which endometrial tissue is also present
outside of the uterus. Some women with endometriosis have no
symptoms, while others experience marked discomfort and pain
and may have problems with fertility.
Chronic pelvic inflammatory
disease Pelvic
inflammatory disease is typically an infection caused by a sexually
transmitted organism. Occasionally, it is caused by a previous
ruptured appendix or scarring resulting from previous pelvic
surgery. It can involve the uterus, ovaries, and fallopian tubes
(narrow tubes that link the ovaries and uterus). Pelvic inflammatory
disease can cause pain, abnormal uterine bleeding, and
symptoms of infection such as fever and chills.
Adenomyosis Adenomyosis is the presence
of endometrial tissue within the uterine muscle. It can cause
an enlarged uterus, pain, and abnormal uterine bleeding.
Uterine leiomyomas Often called fibroids,
these are benign (non-cancerous) tumors in the uterus that can
cause abnormal uterine bleeding and pain.
Some
of the more common non-gynecologic causes of chronic pelvic pain
include:
Irritable bowel syndrome — Irritable
bowel syndrome is a gastrointestinal condition characterized
by chronic abdominal pain and altered bowel habits (such
as loose stools, more frequent bowel movements with onset of pain,
and pain relieved by defecation) in the absence of any
specific cause.
Interstitial cystitis — Interstitial
cystitis is marked by inflammation of the tissues of the bladder
that is not due to infection. Symptoms usually include the
need to urinate frequently (frequency) and a feeling of urgently
needing to urinate (urgency). Some women with interstitial
cystitis present with lower abdominal pain rather than urinary
tract symptoms.
Diverticulitis — A diverticulum
is a sac-like protrusion that sometimes forms in the muscular
wall of the colon (or intestine). Diverticulitis occurs when
diverticula become inflamed. This usually causes abdominal
pain; nausea and vomiting, constipation, diarrhea, and urinary
symptoms can also occur.
Fibromyalgia — Fibromyalgia is one of a group of chronic
pain disorders that affect connective tissue structures, including
muscles, ligaments, and tendons. It is characterized by widespread
muscle pain (or "myalgia")
and tenderness in certain areas of the body. Women with fibromyalgia may
also experience fatigue, sleep disturbances, headaches, and mood disturbances
such as depression and anxiety.
HOW IS THE CAUSE OF CHRONIC PELVIC PAIN
IDENTIFIED? Because
a number of different conditions can cause chronic pelvic pain,
it is sometimes difficult to pinpoint the specific cause. A thorough
history and a physical examination of the abdomen and pelvis are
essential components of the diagnostic work-up. Laboratory tests,
including a white blood cell count, urinalysis, tests for sexually
transmitted infections, and a pregnancy test may be performed.
The lab results may suggest causes of pelvic pain such as infection
or pregnancy.
Some diagnostic procedures may also be helpful in identifying
the cause of chronic pelvic pain. For example, a pelvic ultrasound
examination is very good at detecting pelvic masses, including
ovarian cysts (sometimes caused by ovarian endometriosis) and uterine
fibroids.
A surgical procedure called a laparoscopy may be helpful in diagnosing
some causes of chronic pelvic pain such as endometriosis and chronic
pelvic inflammatory disease. At laparoscopy, a flexible tube with
a special fiberoptic lens is inserted through a small incision
just below the umbilicus. Through the tube, or laparoscope, the
surgeon can visualize the contents of the abdomen, especially the
reproductive organs. If the laparoscopy reveals a normal pelvis,
the physician can then focus the diagnostic and treatment efforts
on non-gynecologic causes of pelvic pain.
HOW IS GYNECOLOGIC PELVIC PAIN TREATED?
Chronic
pelvic pain due to a gynecologic condition is often treated medically.
In some cases, however, surgery may be the treatment of choice.
Medical treatment
Medication
may be prescribed once laboratory and imaging tests suggest the
pain is due to a gynecologic condition. Drugs that may be used
include:
Nonsteroidal anti-inflammatory medications such as ibuprofen
Oral contraceptive pills prescribed
as monthly cycles or as "long
cycles." When
prescribed as long cycles, a woman takes the active pill continuously for
three to four months.
Doxycycline,
an antibiotic used to treat some causes of pelvic inflammatory disease.
Medications called gonadotropin releasing hormone (GnRH) agonist analogues
used to treat endometriosis.
If these medications are not effective in treating the pain,
the woman is sometimes referred to a medical practice specializing
in pain management. Pain services frequently utilize multiple treatment
modalities including acupuncture and behavioral and relaxation
feedback therapies. Nerve stimulation devices or injection of tender
sites with anesthetic agents may also be used. Psychological counseling
may be offered to help women manage the pain. Pain services can
also be helpful in treating women who have become dependent on
narcotics for pain management.
Surgical treatment
A
few causes of gynecologic pelvic pain can be treated surgically.
For example, some women may benefit from surgical removal of
their endometriosis. Uterine fibroids can be excised (a procedure
called myomectomy) or removed as a consequence of hysterectomy
(surgical removal of the uterus). For numerous valid reasons,
many women are reluctant to have a hysterectomy procedure and
prefer to explore options that do not result in removal of the
uterus. Clinicians should be sensitive and responsive to these
preferences.
Hysterectomy may alleviate chronic pelvic pain, especially when
it is due to uterine disorders such as adenomyosis or fibroids.
However, pain can persist even after hysterectomy, particularly
in younger women (those less than 30) and in women with a history
of chronic pelvic inflammatory disease. Hysterectomy is not a good
choice for the management of chronic pelvic pain in women who have
not completed their family.
Surgery to cut some of the nerves in the pelvis has also been
studied as a treatment for chronic pelvic pain. However, the effectiveness
of this approach has not yet been demonstrated.
A
doctor is the best resource for finding out important information
related to your particular case. Not all patients with chronic
pelvic pain are alike, and it is important that your situation
is evaluated by someone who knows you as a whole person.
Pelvic
organ prolapse refers to a hernia of one of the pelvic organs (uterus,
vaginal apex, bladder, rectum) and its associated vaginal segment
from its normal location. Terms used to describe specific types
of female genital prolapse include:
Cystocele: hernia of the bladder with associated descent of the
anterior vaginal segment.
Cystourethrocele: a cystocele combined with distal prolapse of
the urethra (bladder neck) with or without associated urethral
hypermobility.
Uterine prolapse: descent of the uterus and cervix into the lower
vagina, to the hymenal ring, or through the vaginal introitus.
Vaginal vault prolapse: descent of the vaginal apex (following
hysterectomy) into the lower vagina, to the hymenal ring, or
through the vaginal introitus.
Rectocele: hernia of the rectum with associated descent of the
posterior vaginal segment.
Enterocele: herniation of the small bowel/peritoneum into the
vaginal lumen, most commonly presenting following hysterectomy
in conjunction with vaginal vault prolapse.
PREVALENCE
Pelvic
organ prolapse is common. The Women's Health Initiative reported
34 percent of women had anterior vaginal wall, 19 percent had
posterior vaginal wall prolapse, and 14 percent had uterine prolapse.
RISK FACTORS
Risk
factors for pelvic organ prolapse include multiparity (having
multiple children), forceps or vacuum-assisted vaginal delivery,
obesity, advanced age, estrogen deficiency, neurogenic dysfunction
of the pelvic floor, connective tissue disorders, prior pelvic
surgery with disruption of natural support, and chronically increased
intraabdominal pressure (eg, from strenuous physical activity
or coughing). The majority of patients with clinically significant
prolapse will have at least two or more of these factors which
cumulatively, over time, contribute to worsening prolapse as
a women ages.
Women
with prolapse into the vagina often complain of a sensation of
pelvic pressure, a bearing down sensation, inguinal discomfort,
dyspareunia (pain with intercourse), or low back pain. These
symptoms become progressively worse due to a gradual increase in
size of the prolapse over time with repetitive increases in intra-abdominal
pressure. The prolapsed vault may protrude from the vagina on
standing, leading to chronic discharge and bleeding from chronic
ulceration Vaginal wall prolapse is often accompanied by a cystocele,
rectocele, enterocele, or a combination of these disorders. A cystoecele
is a bulging of the anterior vaginal wall down into the vagina
beyond it’s normal limits. Likewise, a bulge in the posterior
vaginal wall is commonly called a rectocele.
The
preoperative evaluation before all surgical procedures should begin
with a careful history and physical examination. Prior to vaginal
vault suspension, it is particularly important to determine whether
the woman had preexisting symptoms of urinary stress incontinence
that resolved due to kinking of the urethra as the vaginal vault
descended. In addition, a significant prolapse should be reduced
manually with a vaginal pack and the patient asked to strain to
check for occult incontinence. In these women, surgical correction
of the vault prolapse will exacerbate incontinence unless steps
are taken to stabilize the bladder neck at surgery. Coexistence
of hiatal or inguinal hernias suggests the presence of chronically
increased intraabdominal pressure, which should be eliminated,
if possible, to enhance the long-term outcome of surgery.
Vaginal
vault prolapse almost always requires surgical correction because
of symptoms that are disruptive to daily life and sexual function.
Although it is a complex disorder, surgery can be curative since
it restores both normal anatomic relationships and vaginal function.
A
pessary is a synthetic device placed into the vagina to keep
it from bulging beyond it’s normal limits. Temporary relief
of symptoms may be obtained with the use of pessaries. These
devices are designed to hold the vault in place against sudden
increases in intraabdominal pressure.
There are four situations in which use of a pessary may be advisable:
Women having only slight or moderate prolapse and achieve symptomatic
relief with a pessary.
Women with marked prolapse who are poor operative risks and who
can be made fairly comfortable with pessary support.
Women with marked prolapse who prefer to get by with the inconvenience
and limited relief of pessary treatment rather than undergo surgery.
Younger women with prolapse who plan to have additional children.
The beneficial effects of extensive vaginal repairs in such women
may be nullified by subsequent pregnancy and childbirth.
Temporary use of a pessary before surgery should be encouraged
in women with severe prolapse who develop ulcerations due to exposure
of the vaginal mucosa and in postmenopausal women who are not taking
hormone replacement therapy. Use of a pessary for two to four weeks
while topical estrogen is administered will allow the vaginal mucosa
to become as healthy as possible before surgery. In addition, women
who desire surgical repair of prolapse, but are unable to schedule
surgery until the distant future, may gain symptomatic relief by
using a pessary in the interim.
SURGICAL TECHNIQUES
The
surgical approach to the management of vaginal vault prolapse
depends upon the woman's desire to preserve sexual function.
Women who are not sexually active and who lead a sedentary lifestyle,
such as some elderly patients, may consider surgical removal
of the vagina (ie, colpectomy) and closing off the space (ie,
colpocleisis). In women in whom preservation of sexual function
is important, the condition can be managed either vaginally or
abdominally. In general, vaginal approaches are favored over
abdominal when both are possible, but many patients require combined
approaches. The physician's expertise plays a role in determining
the surgical approach, as well as the need for other unrelated
procedures.
Transvaginal
sacrospinous colpopexy is performed by suturing one or both sides
of the vagina to the sacrospinous ligament, a structure that can
be used to support and lift the vagina. Alternatively, the vagina
may be sutured to theanother ligament called the iliococcygeus
fascia (transvaginal iliococcygeus colpopexy) for support of the
apex. Both procedures are performed from a vaginal approach without
having to make an abdominal incision.
Transabdominal
sacral colpopexy refers to suspension of the vaginal apex from the sacrum using
synthetic mesh. This is done by from an abdominal incision approach.
Obliterative
surgery is reserved for the patient who no longer desires vaginal
intercourse or in whom body self-image is not an issue. The procedure
is usually performed under general or spinal anesthesia.
Postoperative
care is similar to that following any vaginal reconstructive procedure.
Ambulation The
woman begins walking the day following surgery.
Bowel function Normal
bowel activity is stimulated with a mild laxative the day following
surgery, if necessary. Enemas and suppositories should be avoided.
Bladder drainage Continuous
bladder drainage is not required.
Hormone replacement
therapy Estrogen
therapy, either systemically or locally, is recommended on
a permanent basis.
Pelvic rest The
woman is advised to avoid putting anything in the vagina until
complete healing occurs, typically in three to four weeks. She
should also avoid sudden and repetitive increases in intraabdominal
pressure, constipation, and heavy lifting.
Return to work She
may resume normal activity and return to work when she feels
rested and pain-free. A postoperative examination should be performed
to ensure complete healing before return to work is authorized.
OUTCOME AND PROGNOSIS Women
with recurrent pelvic organ prolapse despite properly executed
previous surgery should be suspected of having generalized connective
tissue weakness. Under these circumstances, the use of synthetic
material will improve the long-term outcome of the planned surgical
reconstruction.
Women with mild prolapse are appropriately treated with pelvic
floor exercises and/or physical therapy with behavioral modification.
Women with moderate prolapse and those who are not ideal surgical
candidates may benefit from use of a pessary. Surgery is the preferred
treatment of severe prolapse. Prognosis depends upon the severity
of symptoms, extent of the prolapse, physician experience, and
patient expectations. Surgery has traditionally been associated
with a recurrence/reoperation rate of up to 30 percent, with some
centers reporting reoperation in over 50 percent of cases; however,
use of site-specific fascial defect repair and graft/mesh augmentation
have improved both prognosis and safety.
URINARY
INCONTINENCE
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care.
INTRODUCTION Urinary
incontinence is the involuntary leakage of urine. Although it
becomes more common as people get older, incontinence is not
normal at any age. Many types of effective therapies are available
for all types of urinary incontinence. A brief review of the
normal process of urination in adults will help in understanding
both the causes and treatment of urinary incontinence.
NORMAL URINATION Most
individuals empty the bladder approximately every three to four
hours during the day, and getting up once during the night to void
is not abnormal for older people. Urine is produced by the kidneys
and passes into a muscular sac called the urinary bladder. A tube
called the urethra leads from the bladder to the outside of the
body.
A special ring of muscles called the urinary sphincter surrounds
the urethra. As the bladder fills with urine, complex nerve signals
ensure that the muscles of the sphincter stay contracted, and that
the muscles of the bladder stay relaxed. This allows the bladder
to fill with urine without urine leaking out of the body.
When the bladder fills to a certain level, nerve signals are
sent to the brain, letting the person know that the bladder is
getting full. Additional nerve signals must be sent in a coordinated
fashion to initiate urination. Some of these signals cause the
bladder muscles to contract, which pushes urine into the urethra.
At the same time, other signals cause the sphincter muscles to
relax, which allows the urine to pass out of the body.
Simply put, four things can go wrong with this process:
The bladder contracts when it shouldn't (when
the person is not ready to urinate). This is the most common
reason people have incontinence.
The bladder fails to contract
properly when it should (leading to a build-up of urine in
the bladder and subsequent leakage). This problem is uncommon.
The
sphincter doesn't close properly or doesn't stay closed when
subjected to pressure (as with a cough or sneeze), allowing
urine to leak. This is a common reason for incontinence in women.
The
urethra is obstructed, preventing the proper drainage of urine,
which can lead to leakage around the obstruction. This is most
common in men with an enlarged prostate.
RISK FACTORS The
prevalence of urinary incontinence increases with age, and it
affects more women than men. About 10 to 30 percent of women,
and 1.5 to 5 percent of men up to age 64 have urinary incontinence.
In those age 65 and older, 15 to 30 percent of individuals living
the community are incontinent, as are at least 50 percent of
those in long-term care facilities.
Urinary incontinence also has been associated with a number of
conditions, including obesity (in women), high impact physical
activities, heart failure, lung problems, smoking, chronic cough,
depression, constipation, pregnancy, vaginal delivery, and problems
with mobility. The impact of each of these factors within a given
individual is difficult to calculate.
Incontinence associated with medical factors — Urinary
incontinence can occur due to a number of treatable factors and
medical problems. As examples, conditions such as urinary tract
infection, pregnancy, or excess fluid intake may temporarily cause
a problem with normal urination. Other potentially treatable factors
sometimes associated with urinary incontinence are the use of certain
medications, excess fluid intake, or fluid retention, diabetes,
and arthritis and other problems causing difficulty walking.
Urge incontinence — Urge
incontinence occurs when the bladder contracts when it shouldn't.
A person with urge incontinence is bothered by an abrupt, overwhelming
urge to urinate, followed by urine leakage that can range from
drops to soaking. The urge and leakage may occur in response to
a stimulus, such as anticipation of urination (for example, unlocking
the door when returning home), going out in the cold, turning on
the faucet, or washing hands. It is particularly common in older
women and men.
Factors that can lead to urge incontinence include age-related
changes in the anatomy of the urinary tract and the physiology
of urination, nervous system problems related to conditions such
as stroke, or bladder irritation caused by factors such as inflammation
or cancer. In some elderly patients, urge incontinence is associated
with bladder contractions that are both involuntary and weak, leading
to leakage of urine due to the involuntary contractions, but also
a build-up of urine in the bladder from inefficient emptying. Doctors
refer to this condition as DHIC (detrusor [bladder muscle] hyperactivity
and impaired detrusor contractile function).
Stress incontinence — Stress
incontinence occurs when the urinary sphincter does not stay closed
when there is an increase in pressure in the abdomen, leading to
urine leakage. As an example, the pressure in the abdomen caused
by coughing, sneezing, laughing, or running can cause episodes
of stress incontinence in susceptible patients. Stress incontinence
is the most common cause of urinary incontinence in younger women,
the second most common cause in older women, and may occur in older
men after certain types of prostate surgery.
Stress incontinence in women is most commonly caused by weakness
in the muscles and other tissues that support the lower urinary
tract. That is, the muscles that help close the sphincter are weak
and ineffective. Less commonly, stress incontinence is caused by
complete failure of the sphincter to close, a condition known as
intrinsic sphincter deficiency (ISD). This can occur with scarring
from surgery.
Mixed incontinence — Mixed
incontinence is the combination of both urge and stress incontinence,
and is most common in younger to middle aged women.
Overflow incontinence — Overflow
incontinence refers to leakage that occurs when the bladder fails
to empty properly, either because of obstruction of the urethra
or weak bladder muscle contractions. When the person tries to urinate,
abnormally large amounts of urine remain in the bladder. There
may be a weak stream, dribbling, and frequent urination. An element
of stress incontinence may occur at the same time, and is usually
related to the failure of the sphincter to remain closed under
stress because of the large bladder volume.
Overflow incontinence is relatively uncommon, but can occur in
some older men in whom either benign or cancerous enlargement of
the prostate (a gland that surrounds the urethra) causes marked
narrowing of the urethra. It is uncommon in women.
DIAGNOSIS — One
of the most important first steps in the diagnosis (and subsequent
treatment) of urinary incontinence is for the patient and clinician
to have a frank discussion about the problem. Studies have shown
that up to one-half of persons with incontinence do not report
the problem to a health care professional. Patients should be
aware that, in most cases, disclosing the problem to the clinician
can lead to an accurate diagnosis and effective treatment.
A number of tools are available to the clinician to help determine
the cause of urinary incontinence.
History and physical examination — The
history and physical examination are among the most important steps
in the investigation and treatment of urinary incontinence. A careful
history of the timing and characteristics of the leakage episodes,
as well as an overall history of the patient's health, will give
important clues as to the cause of incontinence. The patient may
be asked to keep a "bladder diary" for a period of time
to keep track of the timing and amount of urination, (both normal
urination and incontinence) and noting possible associated factors,
such as coughing or sneezing. A physical examination will provide
additional valuable information, such as whether or not there is
evidence of fluid retention and whether nerve function is intact.
The evaluation, particularly in older people, should include
looking for medical conditions, medications, and problems with
mobility that could be contributing to the leakage of urine.
Clinical tests — The
provider may perform some simple tests, such as asking the patient
to cough vigorously and noting whether leakage occurs. The clinician
also may check whether or not the bladder is emptying efficiently
by measuring the amount of urine left in the bladder after normal
urination (postvoid residual urine). The clinician can take this
measurement by asking the patient to urinate, then briefly inserting
a catheter into the bladder to drain any residual urine. Alternatively,
an ultrasound can be used to see if a large volume of urine is
still present.
Laboratory tests — The
clinician will want routine blood and urine tests in order to get
an idea of the overall function of the kidneys. A urine culture
will be done if an infection is suspected.
Urodynamic testing — Urodynamics
refers to a series of tests that examine the bladder, urethra,
and sphincter under various conditions. Examples of tests that
may be done as part of urodynamic testing include measuring the
bladder capacity and how fast urine flows during urination. Other
tests may be done depending on the patient's symptoms. Urodynamic
testing is not recommended as a routine in all cases of incontinence,
but is advisable in certain situations, such as to confirm stress
incontinence or urinary obstruction if surgery is planned.
TREATMENT — The
treatment of urinary incontinence will depend on the type and
presumed cause of the incontinence. In all cases, treatment should
start with the least invasive therapy, such as changes in lifestyle.
As needed, treatment then proceeds to more invasive methods such
as drugs and surgery [2].
Before embarking on a treatment plan, the patient and clinician
should discuss the goals of treatment in detail, as these will
not be the same for every patient. As an example, simply decreasing
the frequency of incontinent episodes may not be the most important
goal for a patient who is most bothered by incontinence during
exercise, or for one who wants most to decrease urinary problems
during the night.
Lifestyle changes — The
clinician may suggest changes in the amount, type, and timing of
beverages. For women, weight loss and stopping smoking may decrease
incontinence. It is important to relax and not strain when voiding
or moving the bowels. Keeping bowel movements regular is important
for healthy urinary voiding. Fluid management also is important,
especially decreasing the evening intake in older people who have
incontinence and frequent voiding at night.
Some foods and beverages are thought to contribute to bladder
leakage. While this has not been definitively proven, it may be
reasonable to see if eliminating one or all of these items helps:
Alcoholic beverages
Carbonated beverages (with
or without caffeine)
Coffee or tea (with or without caffeine)
Citrus
juice and fruits
Tomatoes and tomato-based products
Spicy foods
Artificial sweetener
Chocolate
Corn syrup
Sugar or honey
Potentially reversible factors — The
clinician may make recommendations to treat other factors that
contribute to incontinence. Some examples are changes in medications,
treatment of swollen ankles, improving blood sugar control in diabetics,
and physical therapy for persons with trouble walking.
Behavioral treatment — Behavioral
treatment includes strategies to control urgency and exercises
to strengthen muscles in the pelvis that support the urethra.
Bladder retraining — Bladder
retraining may help urge and stress incontinence. These regimens
help keep the bladder volume low, and retrain the nervous system
and pelvic muscles to better control bladder contractions (show
figure 3). This involves urinating at specific intervals through
the day (usually starting every two hours) whether there is an
urge or not. In addition, the patient is instructed not to run
to the bathroom when an overwhelming urge to urinate occurs, but
to stand still or sit down and concentrate on making the urge decrease.
Once in control of the urge, the patient walks slowly to the bathroom
to urinate. If a decrease in incontinence is seen on this regimen,
the interval between the timed urinations is gradually increased.
For patients with cognitive impairment, behavioral treatment
focuses on encouraging the patient to use the toilet at regular
intervals and by providing positive feedback for successful toileting.
Pelvic muscle exercises — Pelvic
muscle exercises, also known as Kegel exercises, strengthen the
muscles involved in closing the urethral sphincter. These are used
primarily for stress incontinence. Pelvic muscle exercises are
like any other sort of exercise; the emphasis is on short repetitions
of as strong a contraction as possible.
The following steps are important for learning and performing
Kegel exercises:
First, the patient needs to learn to identify which muscles to
contract. This can be done in women by a clinician placing a finger
in the vagina to check that the correct muscles contract. It is
very important that the patient not contract nearby muscles in
buttocks, abdomen, and thighs because these muscles do not control
urine flow. Sometimes, patients are sent for training with special
biofeedback equipment that measures muscle contraction strength
and displays it on a computer screen. Some doctors teach patients
the exercise by having them stop the urine stream while urinating,
but this may not result in the patient squeezing the correct muscles.
Patients should not routinely perform their Kegel exercises while
urinating; the exercises are meant to be done at other times.
Second, the patient is instructed to hold the muscle contraction as long as
possible, and then to relax the muscles (good relaxation is as important as
good contraction). At the beginning, patients may not be able to hold the contraction
for more than one second. The basic recommended regimen is a set of 8 to 12
contractions, repeated three times and done three or four times a week. The
regimen should be continued for at least 15 to 20 weeks.
Over time, the patient should try to hold the contraction harder and for longer,
aiming for a six to eight second hold. These exercises need to be continued
in order to have lasting effect, just like any other form of exercise.
Studies have shown that, if done correctly, pelvic muscle exercises
can be effective in people with stress incontinence. Patients may
benefit from a visit to a physical therapist, or a urology, gynecology,
or geriatric nurse specialist for detailed instructions. Biofeedback
may also help teach correct exercise technique.
The additional use of weighted cones in the vagina or electrical
stimulation devices have not been shown to facilitate pelvic muscle
exercises or improve stress incontinence.
Drug therapy — When
behavioral treatment alone is not successful in treating urge
or mixed incontinence, medicines can be used to suppress bladder
muscle activity. Medicines that are available include:
Oxybutynin comes in three forms: immediate
release (generic oxybutynin), extended release (Ditropan XL®),
and a patch (Oxytrol®).
The immediate release form is particularly useful for people
who require protection at specific times (for example going
out to dinner) since it has a rapid onset of action. Side effects
can include dry mouth, constipation, and visual changes; these
occur less frequently with Ditropan XL®.
Tolterodine also
comes in an immediate release form (Detrol®)
and extended release (Detrol LA®). Side effects are similar
to oxybutynin and Ditropan XL®, but occur less frequently
with Detrol LA®.
Trospium (Sanctura®) comes in an immediate
release form that is taken one or two times daily. Side effects
are generally similar to the other drugs.
Solifenacin (Vesicare®)
is taken once a day. Its effect is similar to that of the above
drugs, but perhaps causes slightly more constipation.
Darifenacin (Enablex®) is taken once a day, and its effect
and side effects are similar to solifenacin.
In general, all of these drugs have similar effectiveness. The
clinician will monitor older patients to make sure these drugs
do not cause urinary retention, which would warrant decreasing
the dose of the medicine. People who do not respond to one drug
can respond to another one. Patients who take these drugs for long
periods of time need to have good dental care, because the dry
mouth can increase the risk of cavities.
Estrogen has been used to treat urinary incontinence in women,
because lack of estrogen after menopause was thought to lead to
weakness in the pelvic muscles and bladder irritation. Large studies
investigating the effectiveness of oral estrogen for treatment
of urinary incontinence have generally shown no benefit or an actual
increase in incontinence. Most experts no longer recommend oral
estrogen therapy. There may still be some benefit in selected women
for topical estrogen that is applied directly to the vaginal area.
Pessary — A
pessary is a device placed in the vagina to support tissues that
have become weak. It may benefit women with stress urinary incontinence
whose problem is made worse by prolapse, or sagging, of the bladder
or uterus. The specially-fitted pessary provides internal support
to the pelvic area, which may help reduce incontinence. Pessaries
are used in older women who are not good candidates for or do not
want surgery to correct prolapse, or as a temporizing measure before
surgery. A pessary must be routinely removed and cleaned.
Surgery — Surgery offers
the highest cure rates for stress urinary incontinence, even in
elderly women. However, it is invasive and can be associated with
complications. The surgical method depends on the underlying defect.
Techniques that support parts of the bladder and/or the urethra
may be used. In some cases, especially when the patient has very
poor sphincter function, so-called "bulking agents" (such
as collagen) are injected around the urethra to provide additional
support. A range of surgical treatments also are used for treatment
of urethral obstruction by the prostate in men.
If surgery is planned, the patient should ask the surgeon for
a detailed explanation of the procedure, the chance of cure, and
any potential complications.
Catheters — Catheters
may be necessary in some patients with overflow incontinence or
who cannot empty their bladders at all. Because catheters have
a high risk of causing urinary tract infections, they should be
a treatment of last resort. Catheters may be left in the bladder,
or used intermittently to drain the bladder. A health care professional
can teach patients and families how to perform a catheterization
at home.
Other measures — In patients
with overflow, other maneuvers that can be effective in draining
a full bladder are massage to the bladder area during urination
(Credé maneuver), "double voiding" (attempting
to urinate again immediately after urinating), and increasing pressure
in the abdomen by "bearing down" on the pelvic area to
help encourage drainage of urine from the bladder (Valsalva maneuver).
These techniques, though they seem simple, should only be done
on instruction from a clinician as side effects such as low heart
rate can occur.
Pads and protective garments should be used only as a last resort.
The choice of garment depends upon gender and the type and volume
of urinary incontinence leakage. As examples, pads designed for
menstrual use often are not sufficiently absorbent for sudden,
larger volume leakage, and men with postvoiding dribbling may prefer
penile sheaths. These items can be expensive and usually not covered
by insurance. Information on pad varieties and other urinary incontinence
supplies is available from medical supply companies and urinary
incontinence patient advocacy groups (see below).
WHERE TO GET MORE INFORMATION — A
clinician is the best resource for finding out important information
related to your particular case. Not all patients with urinary
incontinence are alike, and it is important that your situation
is evaluated by someone who knows you as a whole person.
INTRODUCTION Surgical
sterilization is a safe, highly effective, permanent, and convenient
form of contraception. Numerous methods for achieving permanent
sterilization have been described, and subsequently modified
to improve success rates, simplify surgical technique and reduce
postoperative pain and length of hospital stay. Laparoscopic
techniques (making a small incision near the naval and inserting
a camera for visualization) are preferred for most patients,
as they are effective, and are usually performed on an outpatient
basis, and result in rapid patient recovery. In 1995, almost
30 percent of contraceptive users in the United States used tubal
sterilization.
GENERAL CONSIDERATIONS Tubal
sterilization is an elective and essentially permanent procedure.
There are virtually no absolute contraindications, although a patient's
gynecologic disease may require sterilization by hysterectomy and
bilateral oophorectomy (removing the ovaries).
Known extensive intra-abdominal adhesions
increase the potential for intraoperative morbidity during
laparoscopy. An alternative form of contraception may be preferable,Such
as Essure, which is a new technique without the need for an abdominal
incision (see “Hysteroscopic
sterilization” below).
Informed consent A
woman's decision to undergo sterilization must be voluntary and
not coerced by her family, partner, or health care providers.
Complete, non-biased information about the procedure and alternatives
to surgery help to reduce poststerilization regret. The woman's
husband is not required to give consent before performing the
procedure (in the United States ); however, ideally both partners
should have an understanding of the procedure as well as the
benefits, alternatives, and potential risks. This discussion
includes:
The woman's reasons for choosing sterilization.
Screening
for risk indicators of regret
An explanation of the details
of the procedure, including anesthesia.
The permanence of the
procedure and information on reversal.
The causes and probability
of sterilization failure, including the chance of ectopic pregnancy.
The
need to use condoms for protection against sexually transmitted
diseases (eg, HIV) if she has multiple sex partners or a partner
with other partners.
A reduction in the risk of ovarian cancer
and pelvic inflammatory disease.
No consistent differences in
menstrual cycle characteristics occur as a result of tubal
sterilization.
The patient should have an opportunity to ask questions and express
any concerns that might exist following this discussion. Women
whose sterilization will be federally funded must sign a special
consent document, be at least 21 years of age, and wait 30 days
between signing the consent form and the procedure. Insurance coverage
for the procedure and possible reversal should also be addressed,
as many patients believe if sterilization is covered, reversal
will be too even though this is not usually the case.
Regret after sterilization This
occurs in approximately 3 to 25 percent of women. However, only
about 1 to 2 percent of all women who have undergone sterilization
seek reversal. The most common factor associated with regret is
a change in marital status. Some, but not all, studies also report
an association between regret and marital discord at the time of
procedure.
By comparison, a prospective multicenter series of 7590 women
who were followed for up to five years reported young age at the
time of sterilization was the strongest predictor of regret, regardless
of the number of children they had already delivered or marital
status. The incidence of regret in women aged 20 to 24 years at
sterilization compared to those 30 to 34 years was 4.3 versus 2.4
percent.
Factors not generally related to regret include religious, socioeconomic,
and educational background or low parity at the time of sterilization.
Timing of sterilization Sterilization
can be performed postpartum, postabortion, as an interval procedure
(unrelated to pregnancy), or in conjunction with another surgical
procedure (eg, gall bladder removal). Ideally, postpartum procedures
are performed immediately after delivery or within 24 hours, but
may be done up to seven days later. Further delay increases the
risk of infection and difficulty due to uterine sixe decreasing.
About one-half of procedures are performed postpartum, and follow
10 percent of births.
Luteal phase pregnancy Contraception
should be used for at least one month before sterilization and
continued until the next menstrual cycle to decrease the occurrence
of luteal phase pregnancies. Performance of the procedure postpartum
or during the menstrual or proliferative phase of the cycle reduces
the chance of pregnancy at the time of the procedure. If this is
not practical, a sensitive urine or serum pregnancy test can be
done on the day of the procedure to help detect a luteal phase
pregnancy. Concurrent dilation and curettage (D&C) at the time
of sterilization does not lower the risk of luteal phase pregnancy
(very early pregnancy not detected by pregnancy test at the time
of the procedure) and increases cost and morbidity.
MINILAPAROTOMY STERILIZATION A
minilaparotomy can be used for interval sterilization, but is more
commonly employed for postpartum sterilization. The enlarged uterus
and thinned subumbilical area facilitate exposure through a minilaparotomy
incision just under the navel, while the laparoscopic approach
is much less feasible. General, regional, or local anesthesia all
provide adequate anesthesia.
A potential advantage of laparotomy is that a tissue specimen
is removed (partial salpingectomy) and can provide histologic documentation
of complete transection of the fallopian tubes. However, this can
also be accomplished at laparoscopy if such documentation is important.
Minilaparotomy is also useful if the surgeon is not trained in
laparoscopy or suitable equipment is not available, when the patient
is morbidly obese, or when severe tubal adhesive disease is present.
Disadvantages of minilaparotomy include a higher complication
rate, greater need for postoperative analgesia, longer recovery
time, and a larger surgical incision.
The proximal suture is then cut to allow the tube to retract
into the mesosalpinx and tension is placed on the distal segment
to elevate it above the mesosalpinx. A 3-0 synthetic absorbable
suture is used to reapproximate the serosa so that the proximal
LAPAROSCOPIC STERILIZATION Laparoscopic
sterilization is the most common surgical method for interval sterilization
(sterilization occurring remote from pregnancy). Advantages include
the opportunity to visually explore the abdomen for occult disease,
a small incision, and rapid recovery. However, unexpected intraoperative
findings or complications may necessitate conversion to laparotomy
on occasion.
There are several devices used to tie off the tubes and includes,
clips, elastic bands and electrocauterization (burning the tubes.)
HYSTEROSCOPIC STERILIZATION The
Essure permanent birth control procedure is a minimally invasive
hysteroscopic. In this procedure a camera is inserted into the
vagina and through the cervix into the uterus in order to visualize
the opening of the fallopian tubes. A tiny coil mechanism is inserted
into the fallopian tube hysteroscopically under local anesthesia.
The device appears to induce fibrosis, which occludes the tubes
over a three month period. In clinical studies including several
hundred women, effectiveness at 2 years was 99.8 percent. Patients
must use alternative contraception until a hysterosalpingogram
performed three months postoperatively confirms tubal occlusion.
OUTCOME — Pregnancy
is uncommon after tubal sterilization. The risk appears to be
related to age and the type of procedure.
Ectopic pregnancy — When
pregnancy does occur, the risk that it will be an ectopic pregnancy
is increased over that in the general population [67].
One-third of post sterilization failures are ectopic. In the same
cohort studied above [65],
the 10-year cumulative probability of ectopic pregnancy was 7.3
per 1000 procedures [68].
Again, the risk was related to age and the type of procedure performed.
Women who were under age 30 years at the time of sterilization
were almost twice as likely as older women to have a subsequent
ectopic pregnancy. Bipolar coagulation resulted in the highest
probability of ectopic pregnancy, postpartum partial salpingectomy
the lowest. The risk persisted for many years after the initial
procedure.
Reasons for sterilization failure — Series
of laparoscopic sterilization procedures performed on women who
had previously been sterilized have found [69,70]:
MEDICOLEGAL ISSUES — It
is important to document operative findings carefully if you are
asked to perform a repeat sterilization after a sterilization failure
[72].
Photographs should be taken, if possible. The tube should be resected
and sent to pathology to determine whether a fistula has formed.
In addition:
If an occluding method was used, the lengths of both segments
of tube should be measured and the portion of the tube destroyed
should be identified.
If an electrocoagulation procedure was done, a Mallory trichrome stain can
be performed to document the extent of previous coagulation.
If a Hulka clip was applied, its placement should be documented. Two to 3 cm
from the cornu and at a 90-degree angle to the tubal axis is correct placement.
A thorough discussion of the risks, benefits, and alternatives
to permanent sterilization should take place and informed consent
obtained.
Surgical sterilization is safe (complication rate less than 1 percent) and
effective (overall 10-year probability of pregnancy 18.5 per 1000 procedures,
but varies with type of procedure).
Pregnancies occurring after tubal ligation are more likely to be ectopic (in
the tubes instead of the uterus). The rate of ectopic pregnancy is higher than
that in women using other forms of contraception, but lower than in women not
using any form of contraception.
The procedure should be considered permanent. Reversal may be successful, but
the rate of success is low and it requires major surgery, is costly, and may
not be covered by medical insurance. Regret after sterilization may be related
to young age, conflicted feelings at the time of surgery, or a subsequent change
in marital status.
Laparoscopic sterilization techniques and sterilization by minilaparotomy have
comparable safety and efficacy. The choice of method should be based upon the
clinical situation and patient and physician preference.
Sexual desire/function and menses are not affected by the procedure.
Women who have undergone tubal ligation are less likely to develop ovarian
cancer and pelvic inflammatory disease, but may have a slightly higher rate
of future hysterectomy.
Women with preexisting gynecologic conditions that are often treated hormonally,
such as menorrhagia or irregular menses, may be better served by hormonal contraception.
26),
and 11.5 to 16 kg (25 to 35 lb) for women of average weight (BMI
19.8 to 26.0). This can be achieved with an additional 300 Kcal
per day for average weight women.