To estimate the accuracy of endometrial thickness measurement in the detection of endometrial cancer among women with postmenopausal bleeding with individual patient data using different meta-analytic strategies.Original data sets of studies detected after reviewing the included studies of three previous reviews on this subject. An additional literature search of published articles using MEDLINE databases was preformed from January 2000 to December 2006 to identify articles reporting on endometrial carcinoma and sonographic endometrial thickness measurement in women with postmenopausal bleeding.We identified 90 studies reporting on endometrial thickness measurements and endometrial carcinoma in women with postmenopausal bleeding.We contacted 79 primary investigators to obtain the individual patient data of their reported studies, of which 13 could provide data. Data on 2,896 patients, of which 259 had carcinoma, were included. Several approaches were used in the analyses of the acquired data. First, we performed receiver operator characteristics (ROC) analysis per study, resulting in a summary area under the ROC curve (AUC) calculated as a weighted mean of AUCs from original studies. Second, individual patient data were pooled and analyzed with ROC analyses irrespective of study with standardization of distributional differences across studies using multiples of the median and by random effects logistic regression. Finally, we also used a two-stage procedure, calculating sensitivities and specificities for each study and using the bivariate random effects model to estimate summary estimates for diagnostic accuracy. This resulted in rather comparable ROC curves with AUCs varying between 0.82 and 0.84 and summary estimates for sensitivity and specificity located along these curves. These curves indicated a lower AUC than previously reported meta-analyses using conventional techniques.Previous meta-analyses on endometrial thickness measurement probably have overestimated its diagnostic accuracy in the detection of endometrial carcinoma. We advise the use of cutoff level of 3 mm for exclusion of endometrial carcinoma in women with postmenopausal bleeding.
Pruritus is often considered a common but minor symptom of pregnancy. However, pruritus caused by obstetric cholestasis is increasingly being recognized as a cause of so-called ‘unexplained’ stillbirths. This article reviews recent literature and outlines possible management strategies with the aim of reducing maternal morbidity and improving perinatal outcome.
Training programmes for obstetrics and gynaecology (O&G) and general surgery (GS) vary significantly, but both require proficiency in laparoscopic skills. We sought to determine performance in each specialty.
Objective To determine the feasibility and patient satisfaction of female sterilisation using the Essure™ system in an outpatient hysteroscopy clinic without conscious sedation or general anaesthesia. Design Prospective cohort study. Setting Outpatient hysteroscopy clinic in a large teaching hospital. Population Women undergoing outpatient hysteroscopic sterilisation using the Essure™ system for permanent fertility control. Methods Demographic and procedural data were prospectively collected from 112 consecutive women undergoing outpatient hysteroscopic sterilisation without sedation or general anaesthesia. A hysterosalpingogram (HSG) was performed routinely in all women 3 months after the procedure to confirm bilateral tubal occlusion. Postal questionnaires were sent at this time enquiring about patient satisfaction and experience with the outpatient procedure. Multivariable logistic regression was used to identify factors independently predictive of successful completion of the procedure. Main outcome measures Technical feasibility, predictive factors for technical success (operator, body mass index, uterine size, axis, menstrual phase and cervical stenosis), complications, tubal occlusion on HSG, patient satisfaction and procedure‐related experience. Results Successful bilateral tubal placement of the Essure™ microinserts was achieved in 103/112 (92%, 95% CI 85–96%) women. Nonsecretory phase of the menstrual cycle ( P = 0.04) and a clinically normal‐sized uterus ( P = 0.003) were independently predictive for successful completion of the outpatient procedure on multivariable modelling. There were no major procedure‐related complications recorded, but transient vasovagal reactions occurred in 5/112 (5%) women. Of the original cohort of 112 women with successful procedures, 84 women were 3 months postprocedure and had undergone a HSG. Bilateral tubal occlusion was confirmed in 83/84 (99%, 95% CI 94–100%) women at 3 months and in 100% at 6 months. Seventy‐six of 84 (91%) had returned the questionnaires, and 70/73 (96%, 95% CI 88–99%) were satisfied with their overall experience of the procedure including radiological follow up, with most reporting being ‘very satisfied’ (64/73, 88%, 95% CI 78–94%). Conclusions Outpatient hysteroscopic sterilisation using the Essure™ system without sedation or general anaesthesia is a successful and safe procedure associated with high rates of patient satisfaction. If practical, women should be scheduled to have their procedures in the proliferative phase of the menstrual cycle to optimise successful placement of Essure™ devices, especially if the uterus is clinically enlarged.
The use of quality of life (QoL) instruments in chronic pelvic pain (CPP) will allow a more objective assessment of patient-centred clinical outcomes. However, there is concern that not enough emphasis is placed on clinical face validity (i.e. issues which are of importance to patients and reflect their experiences and concerns). To explore this issue, we performed a systematic review of published research. Relevant papers were identified through electronic scanning of six electronic databases and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with CPP for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for the quality of their QoL instruments using a 17-item checklist, including 10 items for clinical face validity and seven items for measurement (psychometric) properties. A total of 19 articles were eligible for inclusion in the review. The generic Short Form 36 Health Survey Questionnaire (SF-36) was used most frequently, being employed in 10/19 (53%) of the studies. Three studies developed disease-specific QoL instruments for CPP complying with 59 - 77% of the quality criteria. Overall, quality assessment showed that only 4/18 (22.2%) studies complied with more than half the criteria for face validity, whereas 12/18 (66.6%) studies complied with more than half of the criteria for measurement properties (P = 0.0001). Among existing QoL instruments, compliance with the quality criteria for measurement properties is higher than for clinical face validity. There is a need to develop disease specific QoL instruments for CPP with face validity in addition to sound measurement properties.
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