frX-b
*ji src*^-,]ktffe: ^~i^m**±..
Gynecology
Dysfunctional uterine bleeding Dysfunctional uterine bleeding is ab¬ normal endometrial bleeding in patients in whom organic lesions cannot be de¬ monstrated by ordinary means; this entails exclusion of pregnancy, inflam¬ mation and neoplasm. Any patient with abnormal bleeding can be treated only too readily with the "shotgun" therapy of the Pill with much success, but a few patients will suffer because of a missed lesion, late effects of the Pill on pituitary-hypothalamic function, or failure to detect a missing link in the well known pathway, both nervous and humoral, between the higher centres, the pituitary and the uterus. Dysfunctional uterine bleeding is usually anovulatory but may be asso¬ ciated with abnormal function of the corpus luteum or irregular shedding of secretory endometrium. Diagnosis a
Suspicion from history, corroboration by physical examination, and con¬ firmation by endometrial biopsy or currettage constitute the steps in the diag¬ nostic process. Suspicion: The pattern of bleeding whether regular or irregular, spotty or heavy leads one to suspect dys¬ functional bleeding and its type. Emo¬ tional changes, weight variation or pres¬ ence of other endocrine disorders such as diabetes causes one to suspect subtle changes affecting the pituitary-ovarian axis. Headaches and blurred vision sug¬ gest a central disturbance such as a tumour around the pituitary region. Any hormone medication would be of prime importance. Corroboration: Physical examination, both general and local, is essential. Local examination seeks to exclude genital abnormalities such as infections,
* Selected abstracts of papers presented at the POGO refresher course held at the University of Saskatchewan, Saskatoon, Feb. 20 to 22, 1975
foreign bodies, cervical and vaginal tumours, uterine tumours, polycystic ovary syndrome and hormone-producing neoplasms of the ovary. Confirmation: Endometrial biopsy at the time of bleeding is the best confirmatory procedure, and this may show anything from a secretory endo¬ metrium of mature type, to a progestational endometrium with poor develop¬ ment, to a so-called interval endome¬ trium and, last of all, a hyperplastic adenomatous pattern. Further investiga¬ tion may include construction of a ba¬ sal body temperature chart, investiga¬ tion of thyroid function, vaginal smears and cervical mucus arborization for es¬ trogen effect, or radiography of the sella turcica for pituitary tumours. Hematologic investigation should in¬ clude platelet count, prothrombin time, partial thromboplastin test and bleed¬ ing time; and should the results of these be normal, it is unlikely that the blood and vascular system are the cause of any problem. Dilatation and curet¬ tage is in order in many cases, not only for the diagnostic value in providing representative tissue from all areas for histologic evaluation and exclusion of uterine polypi and submucous fibroids, but also for the therapeutic value. About 50% of patients with dysfunc¬ tional bleeding are helped by curettage; this is more beneficial in certain types of bleeding than others. Treatment The specific type of dysfunctional uterine bleeding must be considered. The following types of bleeding should be considered and treated appropriately and, as far as possible, physiologically: 1. Bleeding associated with ovulation. This occurs at mid-cycle and is associated with a sudden decrease in estrogen associated with ovulation. Bleeding may be sufficiently profuse and prolonged to be called a menstrual period; the patient may then be mistakenly assumed to have a cycle of 14
"MkA.'ji^^ .£J
and
Obstetrics*
days. Reassurance usually suffices. If physiologic function is important, es¬ trogen given at this time only will be sufficient to maintain the endometrium. 2. Premenstrual bleeding. Polyps and fibroids should be excluded. This type of bleeding is probably caused by poor function of the corpus luteum; one can confirm this by doing an endo¬ metrial biopsy, which will demonstrate poor progestational endometrium. The logical therapy is to give more progestogen at this time (intramuscularly or orally). 3. Bleeding at intervals shorter than usual. Ovulation and the necessary corpus luteum phase cannot take less than 18 days. Bleeding at shorter inter¬ vals is definitely abnormal. Once secre¬ tory endometrium, even with progesta¬ tional immaturity, has been established, treat by lengthening the prefollicular stage (inhibit follicle-stimulating hor¬ mone by administering estrogens) or by increasing the secretory stage (with clomiphene or progestogens, or with luteinizing hormone releasing factor [LHRF], a product of the hypothalamus that stimulates the pituitary to prolong the luteal phase as yet unavailable). 4. Normal bleeding at intervals longer than usual. Probably no treat¬ ment is required unless the patient is complaining of infertility. 5. Profuse or prolonged bleeding at normal intervals (hypermenorrhea). Pa¬ thologie conditions should be excluded by curettage. This is usually associated with ovulation; curettage is often cura¬ tive. 6. Irregular shedding of the endo¬ metrium due to prolonged survival of a dying corpus luteum. This causes prolonged, profuse flow. One should improve the response to ovulation by giving progestogens in the second part of the cycle, or improve the process of ovulation by giving clomiphene. 7. Constant, unpatterned, intermit¬ tent bleeding. This, the commonest of all types of dysfunctional uterine bleed.
CMA JOURNAL/AUGUST 9, 1975/VOL. 113 223
ing, is the most bothersome. An organic lesion must be ruled out and endome¬ trial biopsy, and probably curettage, is essential, though not often curative. Treatment, as with all categories of dysfunctional uterine bleeding, may vary from reassurance to nutritional ad¬ vice, psychiatric help, curettage, hor¬ monal stimulation, hormonal suppres¬ sion, or even organ ablation. R.J. SOLLARS, MB, FRCS[C], FACOG Medical Arts Clinic 2125 11th Ave. Regina, Sask. -
Recognition of sexual dysfunction in medical practice Problems of counselling for marital and sexual dysfunction 1. Sufficient time is often lacking. 2. Physicians often feel uncomfortable and do not ask about patients' sexual experiences. 3. Sexual problems may be masked by somatic complaints (e.g. lower ab¬ dominal pain, backache, vaginal dis¬ charge and, especially, pruritus vulvae. 4. Patients are reluctant to discuss sexual matters. Many difficulties are related to physician inadequacy in counselling and failure of medical schools to educate students in sexuality. Doctors, like others, often lack factual knowledge about sexuality; students feel their peers are more knowledgeable and experienced, and some have prob¬ lems with their own sexuality. But to counsel patients with sexual problems, a physician must be knowledgeable,
self-confident and
attitudes towards parents, attitudes of medical reasons) rate of 8 to 9%. parents (affectionate, quarrelsome). Copper-carrying IUDs, however, are 3. Joint counselling with female co- smaller, more flexible, and conform
counsellor may be useful. 4. In some cases only information and reassurance are necessary. A wife may wonder if certain forms of sexual stimulation are abnormal and may feel repugnance but may not wish to com¬ municate this to her mate (e.g. oral-
genital practices). 5. In other cases guidance and sup¬ port are required. In perhaps no other field have physicians so great an op¬ portunity for counselling and educating patients: the young woman with dysmenorrhea must be educated about menstruation; the young engaged couple may require a pre-marriage ex¬ amination and may appreciate advice. In particular, physicians can help (a) parents, with problems concerning chil¬ dren's sexual development; (b) young adults and adolescents, about sexual as¬ pects of relationships; (c) married couples, in understanding variant sexu¬ al behaviour; and (d) mature married couples, in becoming familiar with sexual problems associated with ageing and disease. Such problems are usually not amenable to quick cure, but successful treat¬ ment is worth the time spent. Patients may be spared unnecessary medical or surgical treatment. In all sexual coun¬ selling there is a possibility for harm and physicians must be free to use psychologists, psychiatrists, social workers and clergy, among others.
nonjudgemental.
K.M. Crocker, md Department of obstetrics and gynecology University of Saskatchewan
Approach to counselling Initial approach: 1. Medical
history: frequency
Saskatoon, Sask.
of
coitus, pain or discomfort during inter¬ The copper IUD course, orgasmic response, use and abuse of alcohol. The ideal intrauterine device (IUD) Note: must: (a) be compatible with a variety a. Patients are not embarrassed un¬ of uterine shapes and sizes; (b) be easy less physician-counsellor is. to insert; (c) be resistant to expulsion; b. There are no norms for sexual and (d) have few side effects. Among conduct; compatibility of partners is modern IUDs, plastic devices are as¬ vital. sociated with a pregnancy rate of ap¬ c. Dyspareunia: much information is proximately 3 to 4%, an expulsion rate obtainable from enquiry as to type. of 8 to 9% and a discontinuation (for Superficial dyspareunia with insufficient
lubrication is caused by lack of arousal and indicates grave marital difficulty. d. Sexual unresponsiveness indicates need for further exploration. Further exploration: 1. Cooperation of both partners is desirable. History and examination can first be conducted with the female, then the male partner; later, the two may be interviewed together (but males may be unwilling). 2. History must be completely and carefully taken: upbringing, home life, 226 CMA
better to the
shape of the uterine cavity especially the copper-T (Cu-T). They therefore create fewer medical complications. They are highly effec¬
tive. There
two main types of copperIUDs: the Cu-T and the Cu-7. The Cu-T meets many of the criteria for an ideal intrauterine con¬ traceptive. If the plastic-T alone is used, the pregnancy rate is 18 per 100 woman-years. Addition of a copper wire increases effectiveness. The Na¬ tional Research Centre in Fertility and Planning in Montreal has conducted a study of Cu-Ts with surface areas of copper of 200 and 300 mm2. Analysis of the 2000 cases indicates there is no difference in pregnancy rate between the two devices. Rate of copper ab¬ sorption is about 15 /xg/d. There have been no reports of copper toxicity. Antifertility of copper is probably due to a local endometritis; pregnancy will develop normally in one horn of a rat's uterus with a copper-bearing IUD in the other horn. No teratogenic effects have been observed in fetuses carried to term with a copper IUD in situ. We have been unable to duplicate the good results obtained with the Cu-7 by Newton and colleagues1 (Table I). Student health clinic medical person¬ nel estimate the rate of complete or partial expulsion at about 75%, and because of this they have discontinued the use of the Cu-7. Insertion of Cu-Ts is usually easy in nulligravidas and multigravidas. In nulliparas insertion is facilitated during menstruation. If insertion is difficult we use paracervical block. The uterus should be sounded prior to insertion of the device and the collar placed at the depth of the sound. The Cu-7 must be drawn back 2.5 cm from the fundus to allow the vertical arms to expand. Even with this technique we have not found the Cu-7 satisfactory. If preg¬ nancy occurs in association with a cop¬ per IUD the device should be removed by gentle traction.
Table I.Net results of the Cu-T and Cu-7
JOURNAL/AUGUST 9, 1975/VOL.
113
are
carrying
as
contraceptive devices
*ji src*^-,]ktffe: ^~i^m**±..
Gynecology
Dysfunctional uterine bleeding Dysfunctional uterine bleeding is ab¬ normal endometrial bleeding in patients in whom organic lesions cannot be de¬ monstrated by ordinary means; this entails exclusion of pregnancy, inflam¬ mation and neoplasm. Any patient with abnormal bleeding can be treated only too readily with the "shotgun" therapy of the Pill with much success, but a few patients will suffer because of a missed lesion, late effects of the Pill on pituitary-hypothalamic function, or failure to detect a missing link in the well known pathway, both nervous and humoral, between the higher centres, the pituitary and the uterus. Dysfunctional uterine bleeding is usually anovulatory but may be asso¬ ciated with abnormal function of the corpus luteum or irregular shedding of secretory endometrium. Diagnosis a
Suspicion from history, corroboration by physical examination, and con¬ firmation by endometrial biopsy or currettage constitute the steps in the diag¬ nostic process. Suspicion: The pattern of bleeding whether regular or irregular, spotty or heavy leads one to suspect dys¬ functional bleeding and its type. Emo¬ tional changes, weight variation or pres¬ ence of other endocrine disorders such as diabetes causes one to suspect subtle changes affecting the pituitary-ovarian axis. Headaches and blurred vision sug¬ gest a central disturbance such as a tumour around the pituitary region. Any hormone medication would be of prime importance. Corroboration: Physical examination, both general and local, is essential. Local examination seeks to exclude genital abnormalities such as infections,
* Selected abstracts of papers presented at the POGO refresher course held at the University of Saskatchewan, Saskatoon, Feb. 20 to 22, 1975
foreign bodies, cervical and vaginal tumours, uterine tumours, polycystic ovary syndrome and hormone-producing neoplasms of the ovary. Confirmation: Endometrial biopsy at the time of bleeding is the best confirmatory procedure, and this may show anything from a secretory endo¬ metrium of mature type, to a progestational endometrium with poor develop¬ ment, to a so-called interval endome¬ trium and, last of all, a hyperplastic adenomatous pattern. Further investiga¬ tion may include construction of a ba¬ sal body temperature chart, investiga¬ tion of thyroid function, vaginal smears and cervical mucus arborization for es¬ trogen effect, or radiography of the sella turcica for pituitary tumours. Hematologic investigation should in¬ clude platelet count, prothrombin time, partial thromboplastin test and bleed¬ ing time; and should the results of these be normal, it is unlikely that the blood and vascular system are the cause of any problem. Dilatation and curet¬ tage is in order in many cases, not only for the diagnostic value in providing representative tissue from all areas for histologic evaluation and exclusion of uterine polypi and submucous fibroids, but also for the therapeutic value. About 50% of patients with dysfunc¬ tional bleeding are helped by curettage; this is more beneficial in certain types of bleeding than others. Treatment The specific type of dysfunctional uterine bleeding must be considered. The following types of bleeding should be considered and treated appropriately and, as far as possible, physiologically: 1. Bleeding associated with ovulation. This occurs at mid-cycle and is associated with a sudden decrease in estrogen associated with ovulation. Bleeding may be sufficiently profuse and prolonged to be called a menstrual period; the patient may then be mistakenly assumed to have a cycle of 14
"MkA.'ji^^ .£J
and
Obstetrics*
days. Reassurance usually suffices. If physiologic function is important, es¬ trogen given at this time only will be sufficient to maintain the endometrium. 2. Premenstrual bleeding. Polyps and fibroids should be excluded. This type of bleeding is probably caused by poor function of the corpus luteum; one can confirm this by doing an endo¬ metrial biopsy, which will demonstrate poor progestational endometrium. The logical therapy is to give more progestogen at this time (intramuscularly or orally). 3. Bleeding at intervals shorter than usual. Ovulation and the necessary corpus luteum phase cannot take less than 18 days. Bleeding at shorter inter¬ vals is definitely abnormal. Once secre¬ tory endometrium, even with progesta¬ tional immaturity, has been established, treat by lengthening the prefollicular stage (inhibit follicle-stimulating hor¬ mone by administering estrogens) or by increasing the secretory stage (with clomiphene or progestogens, or with luteinizing hormone releasing factor [LHRF], a product of the hypothalamus that stimulates the pituitary to prolong the luteal phase as yet unavailable). 4. Normal bleeding at intervals longer than usual. Probably no treat¬ ment is required unless the patient is complaining of infertility. 5. Profuse or prolonged bleeding at normal intervals (hypermenorrhea). Pa¬ thologie conditions should be excluded by curettage. This is usually associated with ovulation; curettage is often cura¬ tive. 6. Irregular shedding of the endo¬ metrium due to prolonged survival of a dying corpus luteum. This causes prolonged, profuse flow. One should improve the response to ovulation by giving progestogens in the second part of the cycle, or improve the process of ovulation by giving clomiphene. 7. Constant, unpatterned, intermit¬ tent bleeding. This, the commonest of all types of dysfunctional uterine bleed.
CMA JOURNAL/AUGUST 9, 1975/VOL. 113 223
ing, is the most bothersome. An organic lesion must be ruled out and endome¬ trial biopsy, and probably curettage, is essential, though not often curative. Treatment, as with all categories of dysfunctional uterine bleeding, may vary from reassurance to nutritional ad¬ vice, psychiatric help, curettage, hor¬ monal stimulation, hormonal suppres¬ sion, or even organ ablation. R.J. SOLLARS, MB, FRCS[C], FACOG Medical Arts Clinic 2125 11th Ave. Regina, Sask. -
Recognition of sexual dysfunction in medical practice Problems of counselling for marital and sexual dysfunction 1. Sufficient time is often lacking. 2. Physicians often feel uncomfortable and do not ask about patients' sexual experiences. 3. Sexual problems may be masked by somatic complaints (e.g. lower ab¬ dominal pain, backache, vaginal dis¬ charge and, especially, pruritus vulvae. 4. Patients are reluctant to discuss sexual matters. Many difficulties are related to physician inadequacy in counselling and failure of medical schools to educate students in sexuality. Doctors, like others, often lack factual knowledge about sexuality; students feel their peers are more knowledgeable and experienced, and some have prob¬ lems with their own sexuality. But to counsel patients with sexual problems, a physician must be knowledgeable,
self-confident and
attitudes towards parents, attitudes of medical reasons) rate of 8 to 9%. parents (affectionate, quarrelsome). Copper-carrying IUDs, however, are 3. Joint counselling with female co- smaller, more flexible, and conform
counsellor may be useful. 4. In some cases only information and reassurance are necessary. A wife may wonder if certain forms of sexual stimulation are abnormal and may feel repugnance but may not wish to com¬ municate this to her mate (e.g. oral-
genital practices). 5. In other cases guidance and sup¬ port are required. In perhaps no other field have physicians so great an op¬ portunity for counselling and educating patients: the young woman with dysmenorrhea must be educated about menstruation; the young engaged couple may require a pre-marriage ex¬ amination and may appreciate advice. In particular, physicians can help (a) parents, with problems concerning chil¬ dren's sexual development; (b) young adults and adolescents, about sexual as¬ pects of relationships; (c) married couples, in understanding variant sexu¬ al behaviour; and (d) mature married couples, in becoming familiar with sexual problems associated with ageing and disease. Such problems are usually not amenable to quick cure, but successful treat¬ ment is worth the time spent. Patients may be spared unnecessary medical or surgical treatment. In all sexual coun¬ selling there is a possibility for harm and physicians must be free to use psychologists, psychiatrists, social workers and clergy, among others.
nonjudgemental.
K.M. Crocker, md Department of obstetrics and gynecology University of Saskatchewan
Approach to counselling Initial approach: 1. Medical
history: frequency
Saskatoon, Sask.
of
coitus, pain or discomfort during inter¬ The copper IUD course, orgasmic response, use and abuse of alcohol. The ideal intrauterine device (IUD) Note: must: (a) be compatible with a variety a. Patients are not embarrassed un¬ of uterine shapes and sizes; (b) be easy less physician-counsellor is. to insert; (c) be resistant to expulsion; b. There are no norms for sexual and (d) have few side effects. Among conduct; compatibility of partners is modern IUDs, plastic devices are as¬ vital. sociated with a pregnancy rate of ap¬ c. Dyspareunia: much information is proximately 3 to 4%, an expulsion rate obtainable from enquiry as to type. of 8 to 9% and a discontinuation (for Superficial dyspareunia with insufficient
lubrication is caused by lack of arousal and indicates grave marital difficulty. d. Sexual unresponsiveness indicates need for further exploration. Further exploration: 1. Cooperation of both partners is desirable. History and examination can first be conducted with the female, then the male partner; later, the two may be interviewed together (but males may be unwilling). 2. History must be completely and carefully taken: upbringing, home life, 226 CMA
better to the
shape of the uterine cavity especially the copper-T (Cu-T). They therefore create fewer medical complications. They are highly effec¬
tive. There
two main types of copperIUDs: the Cu-T and the Cu-7. The Cu-T meets many of the criteria for an ideal intrauterine con¬ traceptive. If the plastic-T alone is used, the pregnancy rate is 18 per 100 woman-years. Addition of a copper wire increases effectiveness. The Na¬ tional Research Centre in Fertility and Planning in Montreal has conducted a study of Cu-Ts with surface areas of copper of 200 and 300 mm2. Analysis of the 2000 cases indicates there is no difference in pregnancy rate between the two devices. Rate of copper ab¬ sorption is about 15 /xg/d. There have been no reports of copper toxicity. Antifertility of copper is probably due to a local endometritis; pregnancy will develop normally in one horn of a rat's uterus with a copper-bearing IUD in the other horn. No teratogenic effects have been observed in fetuses carried to term with a copper IUD in situ. We have been unable to duplicate the good results obtained with the Cu-7 by Newton and colleagues1 (Table I). Student health clinic medical person¬ nel estimate the rate of complete or partial expulsion at about 75%, and because of this they have discontinued the use of the Cu-7. Insertion of Cu-Ts is usually easy in nulligravidas and multigravidas. In nulliparas insertion is facilitated during menstruation. If insertion is difficult we use paracervical block. The uterus should be sounded prior to insertion of the device and the collar placed at the depth of the sound. The Cu-7 must be drawn back 2.5 cm from the fundus to allow the vertical arms to expand. Even with this technique we have not found the Cu-7 satisfactory. If preg¬ nancy occurs in association with a cop¬ per IUD the device should be removed by gentle traction.
Table I.Net results of the Cu-T and Cu-7
JOURNAL/AUGUST 9, 1975/VOL.
113
are
carrying
as
contraceptive devices
