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Bimanual or ultrasound examination prior to hysterectomy
The dramatic effect of estrogen and progestin in the reduction of hip fracture as studied by these authors is even more impressive. Morbidity and mortality following hip fracture is such that a reduction of risk of this magnitude is a factor that should be discussed with patients during the decision process regarding initiation of hormone replacement therapy and the regimen that is to be used. Estrogen appears to be protective against hip fracture when given at an appropriate dose and the addition of progestin appears to enhance the protective effect.
Postmenopausal Simple Cyst Conway C, Zalud I, Dilena M, Maulik D, Schulman H, Haley J, et al. Simple cyst in the postmenopausalpatient: Detection and management. J Ultrasound Med 1998;17: 369 -72. Synopsis: The authors of this prospective observational study described the prevalence of simple ovarian cysts in asymptomatic postmenopausal women who were enrolled in a 5-year cancer-screening study. O f the 1769 patients, 116 (6.6%) were noted to have simple cysts of the ovary. Color Doppler analysis revealed normal or no detectable blood flow in these cysts. The cysts were between 1.5 and 5.0 cm, were unilocular, and exhibited an anechoic intracystic echo pattern. All patients had an initial CA 125, and all results were in the normal range. Eighteen patients underwent surgical intervention. Two surgeries were due to change in size, and four were due to changes in morphology (detection of septations). The other 12 patients were managed surgically on the basis of physician or patient preference. Twelve of the 18 cysts were serous cystadenomas. All represented a benign process, and one dermoid cyst was noted. At the conclusion of the study, 51 patients (44%) were being :31998 by the American C0ile9e01 0bstetricians aFqdGynec0!00,sts Pubhshed by E1sevier Science Inc 1085-6862/98/$5 50
followed by ultrasound. Twenty patients (17.2%) were lost to follow up, and 27 cysts (23%) resolved spontaneously. Most importantly, there did not appear to be a malignant process in any of the cysts meeting the selection criteria.
C o m m e n t a r y : In addition to the well-publicized lack of cost-effectiveness of universal ultrasound screening for the detection of ovarian cancer in the general population, there is also the problem of how to manage the unexpected small, simple ovarian cyst that is found through serendipity during the scanning procedure. The authors' results support an expectant management posture in these patients. That all of the cysts in this study were benign, a sizeable number spontaneously resolved, and one was a dermoid cyst argues against a cyst drainage management option. O f the 27 cysts that resolved spontaneously, 15 did so in the first 6 months of evaluation. All of those that resolved did so by 2 years. Therefore, a logical management plan based on this analysis is to invoke an expectant posture for 2-3 years and reconsider the surgical option for those cysts that persist after that interval.
Bimanual or Ultrasound Examination Prior to Hysterectomy Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomyfor uterine leiomyoma. Obstet Gynecol 1998;92:109-12. Synopsis: To evaluate the necessity of preoperative ultrasound in the management of uterine leiomyoma, the authors performed a retrospective analysis of 111 patients who underwent hysterectomy for uterine leiomyoma in Miami. Novcmber/l'~ecember
The correlation between ultrasound measurements and bimanual estimates of the size of leiomyomata was excellent. Mathematical equations for the relationship in gestational weeks were presented. The correlation between ultrasound and clinical examination was also excellent in obese patients when the uterus could be palpated. All bimanual examinations were performed by senior residents or attending physicians. An experienced sonographer performed the ultrasound examination.
Commentary: Ultrasound measurement of uterine leiomyomata adds little to the preoperative assessment of the patient and does not contribute a great deal to management planning once the decision to perform hysterectomy has been made. The decision to manage uterine leiomyomata by hysterectomy usually is made to address the symptoms of pain or bleeding. Occasionally, the indication of rapidly enlarging leiomyomata mandate hysterectomy. This study confirms the accuracy of the bimanual examination in assessing uterine size. The utility of ultrasound to preoperatively diagnose leiomyosarcoma remains to be determined. In view of the rarity of this process, the necessity of histopathologic assessment to unequivocally make the diagnosis, and the fact that hysterectomy is the cornerstone of management, preoperative ultrasound can add little to improve accuracy in this diagnosis. A more cogent argument can be made for the use of ultrasound to diagnose the unexpected or subclinical leiomyoma. Specifically, the diagnosis of submucous leiomyomata in patients with abnormal uterine bleeding has expedited the management of these individuals. The recent advent of intrauterine saline instillation in concert with transvaginal imaging has improved the de1998
•
ACOG
CLINICAl,
REVIEW
•
v
tection of intracavitary lesions such as submucous leiomyomata and endometrial polyps. Therefore, a rationale for the use of diagnostic ultrasound can be made for the evaluation of abnormal uterine bleeding to assess the anatomy of the endometrial cavity. The value of ultrasound measurements of the size of uterine leiomyomata palpable by an experienced examiner is questionable.
ERT After Oophorectomy . for Endometr,ous Hickman TN, Namnoum AB, Hinton EL, Zacur HA, RockJA. Timing of estrogen replacement therapy following hysterectomy with oophorectomyfor endometriosis. Obstet Gynecol 1998;91:673-7. Synopsis: To assess the risk of recurrence of the symptoms of endometriosis as a function of the timing of institution of postoperative estrogenreplacement therapy, the authors performed a retrospective cohort study of 95 patients who underwent hysterectomy with oophorectomy at the Johns Hopkins Hospital between 1979 and 1991. Follow-up was obtained by personal interview and review of inpatient and ambulatory records. In the study group of 95 women, 60 began estrogen-replacement therapy in the immediate postoperative period, and 35 were delayed beyond 6 weeks after surgery. Four (7%) of the 60 of those treated immediately postoperatively had a recurrence of pain. Seven (20%) of the 35 of those who had treatment delayed for at least 65 weeks had recurrent pain. The difference was not statistically significant. Early initiation of estrogen-replacement therapy exhibited a relative risk for recurrent pain of 0.33 (95% confidence interval [CI] 0.10, 1.06). The addition of postoperative medroxyprogesterone acetate was not considered to be effective against recurrent pain.The authors acknowl-
edged that the total number of patients in this study was too small to achieve statistical significance. The possibility of a beneficial effect of immediate postoperative estrogen-replacement therapy on the prevalence of recurrent pain in these women remains to be determined.
Commentary: The fear of reactivating endometriosis in the immediate postoperative period following total abdominal hysterectomy and bilateral salpingo-oophorectomy for pelvic endometriosis has long been debated. Concern over the possibility of postoperative thromboembolic disease by early estrogen therapy in the postoperative immobilized patient also has been raised. These data appear to show no adverse effect of immediate institution of estrogen-replacement therapy in the postoperative period as measured by recurrence of pain. Indeed, there appears to be a favorable trend in lessening the risk of pain recurrence with immediate institution of therapy.
The RR of a patient with an affected first-degree relative was calculated to be 3.1 (95% confidence interval [CI] 2.6, 3.7). If the index case was diagnosed before age 40 years, the RR was 1.7 (95% CI 1.2, 2.5). If the index case occurred after age 40, the RR increased to 3.8 (95% CI 2.6, 5.5). The estimated cumulative risk was approximately 4% for women younger than 45 with an affected first-degree relative. This risk declined rapidly with advancing age and reached 1% by age 70. The risk of daughters of affected mothers was 6 (95% CI 3.0, 11.9). The risk of acquiring ovarian cancer by a daughter of an affected mother by age 75 was approximately 7.5%, if the daughter was less than 45 years of age. The risk of mothers of an affected daughter was 1.1 (95% CI 0.8, 1.6). The relative risk for those with a second-degree relative having ovarian cancer was 2.5 (95% CI 1.5 , 4.3). If there were more than one affected relative, the risk appeared to be 11.7 (95% CI 5.3, 25.3). The risk of acquiring ovarian cancer by age 75 in this group was approximately 14% prior to age 45; and although it declined rapidly with age after that, it remained higher than that of the general population.
Risk of Ovarian Cancer With Family History Stratton JF, Pharoah P, Smith SK, Easton D, Ponder BAJ. A systematicreviewand metaanalysisof familyhistory and risk of ovarian cancer. Br J Obstet Gynaecol 1998;105: 493-9. Synopsis: The authors performed a meta-analysis of all studies designed to quantify the risk of ovarian cancer associated with a family history of the disease to assess the relative risk (RR) of patients in a variety of family history subgroups. All published casecontrol and cohort studies were included in the analysis. A total of 16 published studies constituted the basis for this review and the RR calculations.
8 • ACOG CLINICAL REVIEW • November/I)ecember 1998
Commentary: This article supports other studies that show the closer the relationship and the greater number of affected family members, the greater the risk of ovarian cancer. Although there is virtually uniform agreement that screening of the general population for ovarian cancer cannot be justified by scientific data, most studies imply potential justification of using screening techniques in high-risk groups. This study offers a pooled estimate of risk of ovarian cancer in patients with a variety of family history scenarios. ©1998
bytheAmericanCollege0f 0Dsletricfans and Gynec010grsts Publisiqed by Elsevier Science Inc ~085 6862/98/$5.50
Postmenopausal Simple Cyst Conway C, Zalud I, Dilena M, Maulik D, Schulman H, Haley J, et al. Simple cyst in the postmenopausalpatient: Detection and management. J Ultrasound Med 1998;17: 369 -72. Synopsis: The authors of this prospective observational study described the prevalence of simple ovarian cysts in asymptomatic postmenopausal women who were enrolled in a 5-year cancer-screening study. O f the 1769 patients, 116 (6.6%) were noted to have simple cysts of the ovary. Color Doppler analysis revealed normal or no detectable blood flow in these cysts. The cysts were between 1.5 and 5.0 cm, were unilocular, and exhibited an anechoic intracystic echo pattern. All patients had an initial CA 125, and all results were in the normal range. Eighteen patients underwent surgical intervention. Two surgeries were due to change in size, and four were due to changes in morphology (detection of septations). The other 12 patients were managed surgically on the basis of physician or patient preference. Twelve of the 18 cysts were serous cystadenomas. All represented a benign process, and one dermoid cyst was noted. At the conclusion of the study, 51 patients (44%) were being :31998 by the American C0ile9e01 0bstetricians aFqdGynec0!00,sts Pubhshed by E1sevier Science Inc 1085-6862/98/$5 50
followed by ultrasound. Twenty patients (17.2%) were lost to follow up, and 27 cysts (23%) resolved spontaneously. Most importantly, there did not appear to be a malignant process in any of the cysts meeting the selection criteria.
C o m m e n t a r y : In addition to the well-publicized lack of cost-effectiveness of universal ultrasound screening for the detection of ovarian cancer in the general population, there is also the problem of how to manage the unexpected small, simple ovarian cyst that is found through serendipity during the scanning procedure. The authors' results support an expectant management posture in these patients. That all of the cysts in this study were benign, a sizeable number spontaneously resolved, and one was a dermoid cyst argues against a cyst drainage management option. O f the 27 cysts that resolved spontaneously, 15 did so in the first 6 months of evaluation. All of those that resolved did so by 2 years. Therefore, a logical management plan based on this analysis is to invoke an expectant posture for 2-3 years and reconsider the surgical option for those cysts that persist after that interval.
Bimanual or Ultrasound Examination Prior to Hysterectomy Cantuaria GH, Angioli R, Frost L, Duncan R, Penalver MA. Comparison of bimanual examination with ultrasound examination before hysterectomyfor uterine leiomyoma. Obstet Gynecol 1998;92:109-12. Synopsis: To evaluate the necessity of preoperative ultrasound in the management of uterine leiomyoma, the authors performed a retrospective analysis of 111 patients who underwent hysterectomy for uterine leiomyoma in Miami. Novcmber/l'~ecember
The correlation between ultrasound measurements and bimanual estimates of the size of leiomyomata was excellent. Mathematical equations for the relationship in gestational weeks were presented. The correlation between ultrasound and clinical examination was also excellent in obese patients when the uterus could be palpated. All bimanual examinations were performed by senior residents or attending physicians. An experienced sonographer performed the ultrasound examination.
Commentary: Ultrasound measurement of uterine leiomyomata adds little to the preoperative assessment of the patient and does not contribute a great deal to management planning once the decision to perform hysterectomy has been made. The decision to manage uterine leiomyomata by hysterectomy usually is made to address the symptoms of pain or bleeding. Occasionally, the indication of rapidly enlarging leiomyomata mandate hysterectomy. This study confirms the accuracy of the bimanual examination in assessing uterine size. The utility of ultrasound to preoperatively diagnose leiomyosarcoma remains to be determined. In view of the rarity of this process, the necessity of histopathologic assessment to unequivocally make the diagnosis, and the fact that hysterectomy is the cornerstone of management, preoperative ultrasound can add little to improve accuracy in this diagnosis. A more cogent argument can be made for the use of ultrasound to diagnose the unexpected or subclinical leiomyoma. Specifically, the diagnosis of submucous leiomyomata in patients with abnormal uterine bleeding has expedited the management of these individuals. The recent advent of intrauterine saline instillation in concert with transvaginal imaging has improved the de1998
•
ACOG
CLINICAl,
REVIEW
•
v
tection of intracavitary lesions such as submucous leiomyomata and endometrial polyps. Therefore, a rationale for the use of diagnostic ultrasound can be made for the evaluation of abnormal uterine bleeding to assess the anatomy of the endometrial cavity. The value of ultrasound measurements of the size of uterine leiomyomata palpable by an experienced examiner is questionable.
ERT After Oophorectomy . for Endometr,ous Hickman TN, Namnoum AB, Hinton EL, Zacur HA, RockJA. Timing of estrogen replacement therapy following hysterectomy with oophorectomyfor endometriosis. Obstet Gynecol 1998;91:673-7. Synopsis: To assess the risk of recurrence of the symptoms of endometriosis as a function of the timing of institution of postoperative estrogenreplacement therapy, the authors performed a retrospective cohort study of 95 patients who underwent hysterectomy with oophorectomy at the Johns Hopkins Hospital between 1979 and 1991. Follow-up was obtained by personal interview and review of inpatient and ambulatory records. In the study group of 95 women, 60 began estrogen-replacement therapy in the immediate postoperative period, and 35 were delayed beyond 6 weeks after surgery. Four (7%) of the 60 of those treated immediately postoperatively had a recurrence of pain. Seven (20%) of the 35 of those who had treatment delayed for at least 65 weeks had recurrent pain. The difference was not statistically significant. Early initiation of estrogen-replacement therapy exhibited a relative risk for recurrent pain of 0.33 (95% confidence interval [CI] 0.10, 1.06). The addition of postoperative medroxyprogesterone acetate was not considered to be effective against recurrent pain.The authors acknowl-
edged that the total number of patients in this study was too small to achieve statistical significance. The possibility of a beneficial effect of immediate postoperative estrogen-replacement therapy on the prevalence of recurrent pain in these women remains to be determined.
Commentary: The fear of reactivating endometriosis in the immediate postoperative period following total abdominal hysterectomy and bilateral salpingo-oophorectomy for pelvic endometriosis has long been debated. Concern over the possibility of postoperative thromboembolic disease by early estrogen therapy in the postoperative immobilized patient also has been raised. These data appear to show no adverse effect of immediate institution of estrogen-replacement therapy in the postoperative period as measured by recurrence of pain. Indeed, there appears to be a favorable trend in lessening the risk of pain recurrence with immediate institution of therapy.
The RR of a patient with an affected first-degree relative was calculated to be 3.1 (95% confidence interval [CI] 2.6, 3.7). If the index case was diagnosed before age 40 years, the RR was 1.7 (95% CI 1.2, 2.5). If the index case occurred after age 40, the RR increased to 3.8 (95% CI 2.6, 5.5). The estimated cumulative risk was approximately 4% for women younger than 45 with an affected first-degree relative. This risk declined rapidly with advancing age and reached 1% by age 70. The risk of daughters of affected mothers was 6 (95% CI 3.0, 11.9). The risk of acquiring ovarian cancer by a daughter of an affected mother by age 75 was approximately 7.5%, if the daughter was less than 45 years of age. The risk of mothers of an affected daughter was 1.1 (95% CI 0.8, 1.6). The relative risk for those with a second-degree relative having ovarian cancer was 2.5 (95% CI 1.5 , 4.3). If there were more than one affected relative, the risk appeared to be 11.7 (95% CI 5.3, 25.3). The risk of acquiring ovarian cancer by age 75 in this group was approximately 14% prior to age 45; and although it declined rapidly with age after that, it remained higher than that of the general population.
Risk of Ovarian Cancer With Family History Stratton JF, Pharoah P, Smith SK, Easton D, Ponder BAJ. A systematicreviewand metaanalysisof familyhistory and risk of ovarian cancer. Br J Obstet Gynaecol 1998;105: 493-9. Synopsis: The authors performed a meta-analysis of all studies designed to quantify the risk of ovarian cancer associated with a family history of the disease to assess the relative risk (RR) of patients in a variety of family history subgroups. All published casecontrol and cohort studies were included in the analysis. A total of 16 published studies constituted the basis for this review and the RR calculations.
8 • ACOG CLINICAL REVIEW • November/I)ecember 1998
Commentary: This article supports other studies that show the closer the relationship and the greater number of affected family members, the greater the risk of ovarian cancer. Although there is virtually uniform agreement that screening of the general population for ovarian cancer cannot be justified by scientific data, most studies imply potential justification of using screening techniques in high-risk groups. This study offers a pooled estimate of risk of ovarian cancer in patients with a variety of family history scenarios. ©1998
bytheAmericanCollege0f 0Dsletricfans and Gynec010grsts Publisiqed by Elsevier Science Inc ~085 6862/98/$5.50