Kate Johnson

LONDON — Anterior rectal resection and anastomosis for the treatment of rectovaginal endometriosis can provide significant pain relief with an acceptable level of complications, according to a study presented at the annual congress of the International Society for Gynecologic Endoscopy.

“No one knows whether you should perform a rectal resection or simply shave the disease off the surface. An anterior resection is obviously more radical, but the theory is that by doing this you are more likely to remove all of the disease, including microscopic and multifocal disease, and there will be less chance of recurrence,” said Nicholas Kenney, M.D., a clinical fellow at Worthing Hospital (England).

Dr. Kenney presented a review of 37 anterior rectal resections he performed with his colleagues, including his supervisor James English, M.D., a consultant gynecologist at the same hospital.

Of the total 37 procedures, 21 were performed by laparotomy, and the remaining 16 were done by laparoscopy.

In the study, 28 patients (76%) had a primary bowel anastomosis without a stoma, 1 had a preoperative stoma, 2 required a temporary loop colostomy because of low rectal anastomosis, and 6 required a temporary ileostomy because they also underwent either sigmoid, ileal, or cecal resections of endometriosis.

In addition, 31 patients had ovarian preservation, and 14 had their uteri preserved. All 37 patients had positive histology for endometriosis; 21 of those patients had evidence of endometriosis in the muscularis layer of the bowel.

A postoperative survey of patients revealed that in 76% of patients, pain was either completely gone or much better.

Although there were a number of complications, the complication rate was similar to those that have been reported by other groups in association with this surgery, Dr. Kenney said.

In his series, one patient developed a uterovaginal fistula, and another patient developed a rectovaginal fistula, both of which were successfully repaired.

In addition, there were nine rectovaginal anastomotic strictures, which were all managed successfully by balloon dilation under sedation. There also were eight urinary tract infections, one deep vein thrombosis. There was one case of pelvic collection, which was settled with conservative management.

The rectum sticks to the posterior uterine surface in this endometriosis patient. Courtesy Dr. Nicholas Kenney

LONDON — Anterior rectal resection and anastomosis for the treatment of rectovaginal endometriosis can provide significant pain relief with an acceptable level of complications, according to a study presented at the annual congress of the International Society for Gynecologic Endoscopy.

“No one knows whether you should perform a rectal resection or simply shave the disease off the surface. An anterior resection is obviously more radical, but the theory is that by doing this you are more likely to remove all of the disease, including microscopic and multifocal disease, and there will be less chance of recurrence,” said Nicholas Kenney, M.D., a clinical fellow at Worthing Hospital (England).

Dr. Kenney presented a review of 37 anterior rectal resections he performed with his colleagues, including his supervisor James English, M.D., a consultant gynecologist at the same hospital.

Of the total 37 procedures, 21 were performed by laparotomy, and the remaining 16 were done by laparoscopy.

In the study, 28 patients (76%) had a primary bowel anastomosis without a stoma, 1 had a preoperative stoma, 2 required a temporary loop colostomy because of low rectal anastomosis, and 6 required a temporary ileostomy because they also underwent either sigmoid, ileal, or cecal resections of endometriosis.

In addition, 31 patients had ovarian preservation, and 14 had their uteri preserved. All 37 patients had positive histology for endometriosis; 21 of those patients had evidence of endometriosis in the muscularis layer of the bowel.

A postoperative survey of patients revealed that in 76% of patients, pain was either completely gone or much better.

Although there were a number of complications, the complication rate was similar to those that have been reported by other groups in association with this surgery, Dr. Kenney said.

In his series, one patient developed a uterovaginal fistula, and another patient developed a rectovaginal fistula, both of which were successfully repaired.

In addition, there were nine rectovaginal anastomotic strictures, which were all managed successfully by balloon dilation under sedation. There also were eight urinary tract infections, one deep vein thrombosis. There was one case of pelvic collection, which was settled with conservative management.

The rectum sticks to the posterior uterine surface in this endometriosis patient. Courtesy Dr. Nicholas Kenney

LONDON — Anterior rectal resection and anastomosis for the treatment of rectovaginal endometriosis can provide significant pain relief with an acceptable level of complications, according to a study presented at the annual congress of the International Society for Gynecologic Endoscopy.

“No one knows whether you should perform a rectal resection or simply shave the disease off the surface. An anterior resection is obviously more radical, but the theory is that by doing this you are more likely to remove all of the disease, including microscopic and multifocal disease, and there will be less chance of recurrence,” said Nicholas Kenney, M.D., a clinical fellow at Worthing Hospital (England).

Dr. Kenney presented a review of 37 anterior rectal resections he performed with his colleagues, including his supervisor James English, M.D., a consultant gynecologist at the same hospital.

Of the total 37 procedures, 21 were performed by laparotomy, and the remaining 16 were done by laparoscopy.

In the study, 28 patients (76%) had a primary bowel anastomosis without a stoma, 1 had a preoperative stoma, 2 required a temporary loop colostomy because of low rectal anastomosis, and 6 required a temporary ileostomy because they also underwent either sigmoid, ileal, or cecal resections of endometriosis.

In addition, 31 patients had ovarian preservation, and 14 had their uteri preserved. All 37 patients had positive histology for endometriosis; 21 of those patients had evidence of endometriosis in the muscularis layer of the bowel.

A postoperative survey of patients revealed that in 76% of patients, pain was either completely gone or much better.

Although there were a number of complications, the complication rate was similar to those that have been reported by other groups in association with this surgery, Dr. Kenney said.

In his series, one patient developed a uterovaginal fistula, and another patient developed a rectovaginal fistula, both of which were successfully repaired.

In addition, there were nine rectovaginal anastomotic strictures, which were all managed successfully by balloon dilation under sedation. There also were eight urinary tract infections, one deep vein thrombosis. There was one case of pelvic collection, which was settled with conservative management.

The rectum sticks to the posterior uterine surface in this endometriosis patient. Courtesy Dr. Nicholas Kenney

LONDON — The modern infertility work-up should include a transvaginal hydrolaparoscopic exploration of the tubes and ovaries, said Stephan Gordts, M.D., of the Leuven (Belgium) Institute for Fertility and Embryology.

He pioneered transvaginal hydrolaparoscopy (TVL) in 1998 (later, another group named the procedure “fertiloscopy”) and said he's since abandoned tubal assessment by hysterosalpingogram (HSG).

Whereas the HSG can explore tubal patency only, “with TVL you have a more complete exploration of the patient,” he told this newspaper.

Speaking at the annual congress of the International Society for Gynecologic Endoscopy, Dr. Gordts explained that TVL can evaluate both the inside and outside of a patient's reproductive organs and can evaluate adhesions and endometriosis by incorporating hysteroscopy, transvaginal hydrolaparoscopy, salpingoscopy, and tubal patency testing.

TVL can be done in an ambulatory setting, under local anesthetic, and requires only an oocyte aspiration room, rather than a full operating theater. The procedure is performed with the insertion of a needle transvaginally into the pouch of Douglas followed by infusion with saline. An endoscope can be introduced, allowing visualization of the outside of the uterus, the ovaries, and the distal part of the fallopian tubes. The scope can be introduced a few centimeters into the distal end of the fallopian tube for evaluation of the ampulla and the inside of the distal tube. A biopsy can reveal the presence or absence of normal cilia movement.

At the same time, a hysteroscope can be passed through the cervix, allowing evaluation of the inside of the uterus, and infusion of dye through the fallopian tubes to assess their patency.

The presence of saline makes adhesions and subtle endometriotic lesions float, allowing for easier identification. “This pathology is often masked under the high intraabdominal pressure of laparoscopy,” Dr. Gordts said.

Although it's primarily a diagnostic procedure, TVL can be used to perform adhesiolysis, treat mild to moderate endometriosis, and drill ovaries in patients with polycystic ovarian disease.

Unlike Dr. Gordts, Jacques Donnez, M.D., said he believes there is still a place for HSG in the fertility work-up—and the combination of HSG and TVL might offer the most thorough tubal assessment.

Although TVL can visualize a few centimeters of the inner distal fallopian tube, and evaluate patency by confirming spillage of dye infused through the cervix, it offers no other information about the status of the proximal tube, said the professor and head of gynecology at Catholic University of Louvain in Brussels.

“You can see if the dye is not going through, but if this happens you have no idea of the location of the blockage or if there is some diverticuli or anomalies in the proximal tube,” he said in an interview.

HSG can identify the location of proximal blockages, some of which can be easily catheterized.

LONDON — The modern infertility work-up should include a transvaginal hydrolaparoscopic exploration of the tubes and ovaries, said Stephan Gordts, M.D., of the Leuven (Belgium) Institute for Fertility and Embryology.

He pioneered transvaginal hydrolaparoscopy (TVL) in 1998 (later, another group named the procedure “fertiloscopy”) and said he's since abandoned tubal assessment by hysterosalpingogram (HSG).

Whereas the HSG can explore tubal patency only, “with TVL you have a more complete exploration of the patient,” he told this newspaper.

Speaking at the annual congress of the International Society for Gynecologic Endoscopy, Dr. Gordts explained that TVL can evaluate both the inside and outside of a patient's reproductive organs and can evaluate adhesions and endometriosis by incorporating hysteroscopy, transvaginal hydrolaparoscopy, salpingoscopy, and tubal patency testing.

TVL can be done in an ambulatory setting, under local anesthetic, and requires only an oocyte aspiration room, rather than a full operating theater. The procedure is performed with the insertion of a needle transvaginally into the pouch of Douglas followed by infusion with saline. An endoscope can be introduced, allowing visualization of the outside of the uterus, the ovaries, and the distal part of the fallopian tubes. The scope can be introduced a few centimeters into the distal end of the fallopian tube for evaluation of the ampulla and the inside of the distal tube. A biopsy can reveal the presence or absence of normal cilia movement.

At the same time, a hysteroscope can be passed through the cervix, allowing evaluation of the inside of the uterus, and infusion of dye through the fallopian tubes to assess their patency.

The presence of saline makes adhesions and subtle endometriotic lesions float, allowing for easier identification. “This pathology is often masked under the high intraabdominal pressure of laparoscopy,” Dr. Gordts said.

Although it's primarily a diagnostic procedure, TVL can be used to perform adhesiolysis, treat mild to moderate endometriosis, and drill ovaries in patients with polycystic ovarian disease.

Unlike Dr. Gordts, Jacques Donnez, M.D., said he believes there is still a place for HSG in the fertility work-up—and the combination of HSG and TVL might offer the most thorough tubal assessment.

Although TVL can visualize a few centimeters of the inner distal fallopian tube, and evaluate patency by confirming spillage of dye infused through the cervix, it offers no other information about the status of the proximal tube, said the professor and head of gynecology at Catholic University of Louvain in Brussels.

“You can see if the dye is not going through, but if this happens you have no idea of the location of the blockage or if there is some diverticuli or anomalies in the proximal tube,” he said in an interview.

HSG can identify the location of proximal blockages, some of which can be easily catheterized.

LONDON — The modern infertility work-up should include a transvaginal hydrolaparoscopic exploration of the tubes and ovaries, said Stephan Gordts, M.D., of the Leuven (Belgium) Institute for Fertility and Embryology.

He pioneered transvaginal hydrolaparoscopy (TVL) in 1998 (later, another group named the procedure “fertiloscopy”) and said he's since abandoned tubal assessment by hysterosalpingogram (HSG).

Whereas the HSG can explore tubal patency only, “with TVL you have a more complete exploration of the patient,” he told this newspaper.

Speaking at the annual congress of the International Society for Gynecologic Endoscopy, Dr. Gordts explained that TVL can evaluate both the inside and outside of a patient's reproductive organs and can evaluate adhesions and endometriosis by incorporating hysteroscopy, transvaginal hydrolaparoscopy, salpingoscopy, and tubal patency testing.

TVL can be done in an ambulatory setting, under local anesthetic, and requires only an oocyte aspiration room, rather than a full operating theater. The procedure is performed with the insertion of a needle transvaginally into the pouch of Douglas followed by infusion with saline. An endoscope can be introduced, allowing visualization of the outside of the uterus, the ovaries, and the distal part of the fallopian tubes. The scope can be introduced a few centimeters into the distal end of the fallopian tube for evaluation of the ampulla and the inside of the distal tube. A biopsy can reveal the presence or absence of normal cilia movement.

At the same time, a hysteroscope can be passed through the cervix, allowing evaluation of the inside of the uterus, and infusion of dye through the fallopian tubes to assess their patency.

The presence of saline makes adhesions and subtle endometriotic lesions float, allowing for easier identification. “This pathology is often masked under the high intraabdominal pressure of laparoscopy,” Dr. Gordts said.

Although it's primarily a diagnostic procedure, TVL can be used to perform adhesiolysis, treat mild to moderate endometriosis, and drill ovaries in patients with polycystic ovarian disease.

Unlike Dr. Gordts, Jacques Donnez, M.D., said he believes there is still a place for HSG in the fertility work-up—and the combination of HSG and TVL might offer the most thorough tubal assessment.

Although TVL can visualize a few centimeters of the inner distal fallopian tube, and evaluate patency by confirming spillage of dye infused through the cervix, it offers no other information about the status of the proximal tube, said the professor and head of gynecology at Catholic University of Louvain in Brussels.

“You can see if the dye is not going through, but if this happens you have no idea of the location of the blockage or if there is some diverticuli or anomalies in the proximal tube,” he said in an interview.

HSG can identify the location of proximal blockages, some of which can be easily catheterized.

LONDON — Patients with chronic pelvic pain and mild endometriosis can get temporary relief from excision or ablation of their lesions almost 70% of the time, according to a randomized controlled trial of both treatments.

“If you look at patients who have purely superficial lesions, not patients with infiltrating disease or ovarian cysts, regardless of which treatment, 67% will report pain relief 6 months after the procedure,” said principal investigator Jeremy T. Wright, M.B., president of the British Society for Gynaecological Endoscopy, and a consultant gynecologist at Woking (England) Nuffield Hospital and Ashford and St Peter's Hospitals NHS Trust, Chertsey, England.

The study, which Dr. Wright reported at the annual congress of the International Society for Gynecologic Endoscopy, included 22 chronic pelvic pain patients with mild endometriosis, meaning they had revised American Fertility Society scores of 1–2. The patients were randomized at the time of laparoscopy to either excision of the lesions or ablation using monopolar diathermy.

Before the procedure, participants in the study were asked to complete a symptom questionnaire that included a pain rating. Specific areas of pelvic tenderness also were identified and rated. This evaluation was then repeated at 6 months post procedure, at which time participants and investigators were blinded to the treatment modality.

At 6 months, both treatments apparently produced good symptomatic relief and reduction of pelvic tenderness in most patients. Two patients in the ablation group reported no relief, or a worsening of symptoms or signs, but this was not significant statistically, according to Dr. Wright.

In addition, two patients involved in the study—one from each treatment group—became pregnant during the follow-up period.

“These findings show that at diagnostic laparoscopy, there's nothing to stop generalists from treating superficial lesions with the expectation that this will provide pain relief,” Dr. Wright said in an interview.

He added that although the results for both treatments were equal, he believes ablation could possibly result in less thorough treatment.

“If you are coagulating over great vessels or the ureter or part of the bowel, the coagulative process may extend to damage those structures, and so people are a bit jumpy about burning onto those structures.

On the other hand, if you are excising tissue, you are pulling it away from those structures and then cutting it, so you are much less likely to damage them. That means that with excision, you are more likely to be able to complete the treatment without leaving areas untreated,” Dr. Wright said.

The researchers have continued following patients, and although a formal analysis of the data was not presented, Dr. Wright says it appears that pain relief does not persist.

At 18 months, the patients say their quality of life has improved. But if you repeat their pain measurements, they are not much better in terms of global pain scores.

The American College of Obstetricians and Gynecologists recently released Committee Opinion #310, which states that “after a comprehensive preoperative evaluation and trial of combination hormone therapy and NSAIDs to treat dysmenorrhea,” laparoscopy should be recommended for diagnosing and for treating presumed endometriosis in adolescent patients. (Obstet. Gynecol. 2005;105:921–7).

According to the opinion, the objective of the therapy should be “suppression of pain, suppression of disease progression, and preservation of fertility.” With this in mind, the document recommends postsurgical medical therapy until the patients have completed child bearing.

LONDON — Patients with chronic pelvic pain and mild endometriosis can get temporary relief from excision or ablation of their lesions almost 70% of the time, according to a randomized controlled trial of both treatments.

“If you look at patients who have purely superficial lesions, not patients with infiltrating disease or ovarian cysts, regardless of which treatment, 67% will report pain relief 6 months after the procedure,” said principal investigator Jeremy T. Wright, M.B., president of the British Society for Gynaecological Endoscopy, and a consultant gynecologist at Woking (England) Nuffield Hospital and Ashford and St Peter's Hospitals NHS Trust, Chertsey, England.

The study, which Dr. Wright reported at the annual congress of the International Society for Gynecologic Endoscopy, included 22 chronic pelvic pain patients with mild endometriosis, meaning they had revised American Fertility Society scores of 1–2. The patients were randomized at the time of laparoscopy to either excision of the lesions or ablation using monopolar diathermy.

Before the procedure, participants in the study were asked to complete a symptom questionnaire that included a pain rating. Specific areas of pelvic tenderness also were identified and rated. This evaluation was then repeated at 6 months post procedure, at which time participants and investigators were blinded to the treatment modality.

At 6 months, both treatments apparently produced good symptomatic relief and reduction of pelvic tenderness in most patients. Two patients in the ablation group reported no relief, or a worsening of symptoms or signs, but this was not significant statistically, according to Dr. Wright.

In addition, two patients involved in the study—one from each treatment group—became pregnant during the follow-up period.

“These findings show that at diagnostic laparoscopy, there's nothing to stop generalists from treating superficial lesions with the expectation that this will provide pain relief,” Dr. Wright said in an interview.

He added that although the results for both treatments were equal, he believes ablation could possibly result in less thorough treatment.

“If you are coagulating over great vessels or the ureter or part of the bowel, the coagulative process may extend to damage those structures, and so people are a bit jumpy about burning onto those structures.

On the other hand, if you are excising tissue, you are pulling it away from those structures and then cutting it, so you are much less likely to damage them. That means that with excision, you are more likely to be able to complete the treatment without leaving areas untreated,” Dr. Wright said.

The researchers have continued following patients, and although a formal analysis of the data was not presented, Dr. Wright says it appears that pain relief does not persist.

At 18 months, the patients say their quality of life has improved. But if you repeat their pain measurements, they are not much better in terms of global pain scores.

The American College of Obstetricians and Gynecologists recently released Committee Opinion #310, which states that “after a comprehensive preoperative evaluation and trial of combination hormone therapy and NSAIDs to treat dysmenorrhea,” laparoscopy should be recommended for diagnosing and for treating presumed endometriosis in adolescent patients. (Obstet. Gynecol. 2005;105:921–7).

According to the opinion, the objective of the therapy should be “suppression of pain, suppression of disease progression, and preservation of fertility.” With this in mind, the document recommends postsurgical medical therapy until the patients have completed child bearing.

LONDON — Patients with chronic pelvic pain and mild endometriosis can get temporary relief from excision or ablation of their lesions almost 70% of the time, according to a randomized controlled trial of both treatments.

“If you look at patients who have purely superficial lesions, not patients with infiltrating disease or ovarian cysts, regardless of which treatment, 67% will report pain relief 6 months after the procedure,” said principal investigator Jeremy T. Wright, M.B., president of the British Society for Gynaecological Endoscopy, and a consultant gynecologist at Woking (England) Nuffield Hospital and Ashford and St Peter's Hospitals NHS Trust, Chertsey, England.

The study, which Dr. Wright reported at the annual congress of the International Society for Gynecologic Endoscopy, included 22 chronic pelvic pain patients with mild endometriosis, meaning they had revised American Fertility Society scores of 1–2. The patients were randomized at the time of laparoscopy to either excision of the lesions or ablation using monopolar diathermy.

Before the procedure, participants in the study were asked to complete a symptom questionnaire that included a pain rating. Specific areas of pelvic tenderness also were identified and rated. This evaluation was then repeated at 6 months post procedure, at which time participants and investigators were blinded to the treatment modality.

At 6 months, both treatments apparently produced good symptomatic relief and reduction of pelvic tenderness in most patients. Two patients in the ablation group reported no relief, or a worsening of symptoms or signs, but this was not significant statistically, according to Dr. Wright.

In addition, two patients involved in the study—one from each treatment group—became pregnant during the follow-up period.

“These findings show that at diagnostic laparoscopy, there's nothing to stop generalists from treating superficial lesions with the expectation that this will provide pain relief,” Dr. Wright said in an interview.

He added that although the results for both treatments were equal, he believes ablation could possibly result in less thorough treatment.

“If you are coagulating over great vessels or the ureter or part of the bowel, the coagulative process may extend to damage those structures, and so people are a bit jumpy about burning onto those structures.

On the other hand, if you are excising tissue, you are pulling it away from those structures and then cutting it, so you are much less likely to damage them. That means that with excision, you are more likely to be able to complete the treatment without leaving areas untreated,” Dr. Wright said.

The researchers have continued following patients, and although a formal analysis of the data was not presented, Dr. Wright says it appears that pain relief does not persist.

At 18 months, the patients say their quality of life has improved. But if you repeat their pain measurements, they are not much better in terms of global pain scores.

The American College of Obstetricians and Gynecologists recently released Committee Opinion #310, which states that “after a comprehensive preoperative evaluation and trial of combination hormone therapy and NSAIDs to treat dysmenorrhea,” laparoscopy should be recommended for diagnosing and for treating presumed endometriosis in adolescent patients. (Obstet. Gynecol. 2005;105:921–7).

According to the opinion, the objective of the therapy should be “suppression of pain, suppression of disease progression, and preservation of fertility.” With this in mind, the document recommends postsurgical medical therapy until the patients have completed child bearing.

MONTREAL – Comorbid eating disorders and substance abuse are intertwined behaviorally and biologically, so the treatment of both problems must be an integrated effort, Cynthia M. Bulik, Ph.D., said at an international conference sponsored by the Academy for Eating Disorders.

And with growing numbers of middle-aged women presenting to eating disorder programs, substance abuse comorbidity is being seen more frequently than in the teenage population, she said.

“We don't have sufficient integrated treatment programs, so often patients will go to substance abuse programs which either ignore or are ill equipped to deal with their eating disorder, and then they are sent to an eating disorders program without necessarily the proper follow-up for their substance abuse,” said Dr. Bulik, professor of eating disorders and nutrition at the University of North Carolina, Chapel Hill.

Although the abuse of certain substances, such as laxatives or diet pills, may have superficial connections to the desire for weight loss, the abuse is almost always intertwined with other complex psychiatric issues, Dr. Bulik explained.

“If we try to discourage a patient from abusing laxatives by pointing out that they are ineffective as weight loss agents, we are missing the mark clinically, because there's a real self-harm component to this behavior,” she said in an interview. “When a person takes 50 laxatives a day, it hurts, there's incredible cramping and diarrhea, it keeps them up at night, and it's very painful. If we fail to address this whole self-punishing aspect, we're really not addressing their needs.”

Indeed, she and her associates have found that laxative abuse, most common among patients with purging anorexia (72%) and combined anorexia and bulimia nervosa (59%), is associated with a significantly higher prevalence of borderline personality disorder–characterized particularly by feelings of suicidality, self-harm, emptiness, and anger, she reported.

In another study, they found that alcohol abuse is more prevalent in patients with bulimia nervosa (46%) and combined bulimia and anorexia nervosa (37%), compared with those with anorexia (16%) alone (J. Clin. Psychiatry 2004;65:1000–6). Other studies have suggested anywhere from two to six times the risk of alcohol dependency in the eating disordered population, compared with the general population, she said.

As with laxative abuse, alcohol abuse in patients with eating disorders occurs with other psychiatric comorbidities such as major depressive disorder, obsessive compulsive disorder, posttraumatic stress disorder, social phobia, borderline personality disorder, and perfectionism–all of which need to be evaluated and treated, Dr. Bulik said.

In addition, other drugs such as nicotine and caffeine should be considered more problematic in patients with eating disorders than in healthy individuals, she said. In such patients, these drugs can actually be part of the eating disorder.

Research suggests that smoking can significantly increase resting energy expenditure, making it counterproductive to treatment because it can interfere with the treatment goal of weight restoration; caffeine is used to overcome some of the fatigue caused by undernourishment.

“There's both a cognitive component and a physiologic component to this kind of drug use. Patients know that nicotine increases their metabolism, and they know that caffeine might be giving them false energy when they are not eating,” she said.

In addition, cravings for all drugs are enhanced with food deprivation, a neurobiologic factor that could interfere with drug abuse rehabilitation.

“People need reinforcers, and food is the major reinforcer. Just like in laboratory animals, when you take food away, they often turn to other substances,” Dr. Bulik said.

Careful attention to patterns and changes in patients' substance abuse can offer important insight when tracking their eating disorder, and vice versa. It can also help in the prediction or prevention of relapse.

As an example, she described a person who may have gained control of her eating disorder but not her alcohol abuse. Because alcohol disinhibits appetite, it could trigger binge eating that could trigger a relapse of the eating disorder. Similarly, if a patient is unable to decrease her nicotine consumption, this could be an indication that her eating disorder is not well controlled.

“We need to focus on integrated treatments where we are dealing with both things at the same time, looking at how they interrelate, understanding what some of the overarching integrators might be, and exploring how substances can influence relapse,” Dr. Bulik said.

MONTREAL – Comorbid eating disorders and substance abuse are intertwined behaviorally and biologically, so the treatment of both problems must be an integrated effort, Cynthia M. Bulik, Ph.D., said at an international conference sponsored by the Academy for Eating Disorders.

And with growing numbers of middle-aged women presenting to eating disorder programs, substance abuse comorbidity is being seen more frequently than in the teenage population, she said.

“We don't have sufficient integrated treatment programs, so often patients will go to substance abuse programs which either ignore or are ill equipped to deal with their eating disorder, and then they are sent to an eating disorders program without necessarily the proper follow-up for their substance abuse,” said Dr. Bulik, professor of eating disorders and nutrition at the University of North Carolina, Chapel Hill.

Although the abuse of certain substances, such as laxatives or diet pills, may have superficial connections to the desire for weight loss, the abuse is almost always intertwined with other complex psychiatric issues, Dr. Bulik explained.

“If we try to discourage a patient from abusing laxatives by pointing out that they are ineffective as weight loss agents, we are missing the mark clinically, because there's a real self-harm component to this behavior,” she said in an interview. “When a person takes 50 laxatives a day, it hurts, there's incredible cramping and diarrhea, it keeps them up at night, and it's very painful. If we fail to address this whole self-punishing aspect, we're really not addressing their needs.”

Indeed, she and her associates have found that laxative abuse, most common among patients with purging anorexia (72%) and combined anorexia and bulimia nervosa (59%), is associated with a significantly higher prevalence of borderline personality disorder–characterized particularly by feelings of suicidality, self-harm, emptiness, and anger, she reported.

In another study, they found that alcohol abuse is more prevalent in patients with bulimia nervosa (46%) and combined bulimia and anorexia nervosa (37%), compared with those with anorexia (16%) alone (J. Clin. Psychiatry 2004;65:1000–6). Other studies have suggested anywhere from two to six times the risk of alcohol dependency in the eating disordered population, compared with the general population, she said.

As with laxative abuse, alcohol abuse in patients with eating disorders occurs with other psychiatric comorbidities such as major depressive disorder, obsessive compulsive disorder, posttraumatic stress disorder, social phobia, borderline personality disorder, and perfectionism–all of which need to be evaluated and treated, Dr. Bulik said.

In addition, other drugs such as nicotine and caffeine should be considered more problematic in patients with eating disorders than in healthy individuals, she said. In such patients, these drugs can actually be part of the eating disorder.

Research suggests that smoking can significantly increase resting energy expenditure, making it counterproductive to treatment because it can interfere with the treatment goal of weight restoration; caffeine is used to overcome some of the fatigue caused by undernourishment.

“There's both a cognitive component and a physiologic component to this kind of drug use. Patients know that nicotine increases their metabolism, and they know that caffeine might be giving them false energy when they are not eating,” she said.

In addition, cravings for all drugs are enhanced with food deprivation, a neurobiologic factor that could interfere with drug abuse rehabilitation.

“People need reinforcers, and food is the major reinforcer. Just like in laboratory animals, when you take food away, they often turn to other substances,” Dr. Bulik said.

Careful attention to patterns and changes in patients' substance abuse can offer important insight when tracking their eating disorder, and vice versa. It can also help in the prediction or prevention of relapse.

As an example, she described a person who may have gained control of her eating disorder but not her alcohol abuse. Because alcohol disinhibits appetite, it could trigger binge eating that could trigger a relapse of the eating disorder. Similarly, if a patient is unable to decrease her nicotine consumption, this could be an indication that her eating disorder is not well controlled.

“We need to focus on integrated treatments where we are dealing with both things at the same time, looking at how they interrelate, understanding what some of the overarching integrators might be, and exploring how substances can influence relapse,” Dr. Bulik said.

MONTREAL – Comorbid eating disorders and substance abuse are intertwined behaviorally and biologically, so the treatment of both problems must be an integrated effort, Cynthia M. Bulik, Ph.D., said at an international conference sponsored by the Academy for Eating Disorders.

And with growing numbers of middle-aged women presenting to eating disorder programs, substance abuse comorbidity is being seen more frequently than in the teenage population, she said.

“We don't have sufficient integrated treatment programs, so often patients will go to substance abuse programs which either ignore or are ill equipped to deal with their eating disorder, and then they are sent to an eating disorders program without necessarily the proper follow-up for their substance abuse,” said Dr. Bulik, professor of eating disorders and nutrition at the University of North Carolina, Chapel Hill.

Although the abuse of certain substances, such as laxatives or diet pills, may have superficial connections to the desire for weight loss, the abuse is almost always intertwined with other complex psychiatric issues, Dr. Bulik explained.

“If we try to discourage a patient from abusing laxatives by pointing out that they are ineffective as weight loss agents, we are missing the mark clinically, because there's a real self-harm component to this behavior,” she said in an interview. “When a person takes 50 laxatives a day, it hurts, there's incredible cramping and diarrhea, it keeps them up at night, and it's very painful. If we fail to address this whole self-punishing aspect, we're really not addressing their needs.”

Indeed, she and her associates have found that laxative abuse, most common among patients with purging anorexia (72%) and combined anorexia and bulimia nervosa (59%), is associated with a significantly higher prevalence of borderline personality disorder–characterized particularly by feelings of suicidality, self-harm, emptiness, and anger, she reported.

In another study, they found that alcohol abuse is more prevalent in patients with bulimia nervosa (46%) and combined bulimia and anorexia nervosa (37%), compared with those with anorexia (16%) alone (J. Clin. Psychiatry 2004;65:1000–6). Other studies have suggested anywhere from two to six times the risk of alcohol dependency in the eating disordered population, compared with the general population, she said.

As with laxative abuse, alcohol abuse in patients with eating disorders occurs with other psychiatric comorbidities such as major depressive disorder, obsessive compulsive disorder, posttraumatic stress disorder, social phobia, borderline personality disorder, and perfectionism–all of which need to be evaluated and treated, Dr. Bulik said.

In addition, other drugs such as nicotine and caffeine should be considered more problematic in patients with eating disorders than in healthy individuals, she said. In such patients, these drugs can actually be part of the eating disorder.

Research suggests that smoking can significantly increase resting energy expenditure, making it counterproductive to treatment because it can interfere with the treatment goal of weight restoration; caffeine is used to overcome some of the fatigue caused by undernourishment.

“There's both a cognitive component and a physiologic component to this kind of drug use. Patients know that nicotine increases their metabolism, and they know that caffeine might be giving them false energy when they are not eating,” she said.

In addition, cravings for all drugs are enhanced with food deprivation, a neurobiologic factor that could interfere with drug abuse rehabilitation.

“People need reinforcers, and food is the major reinforcer. Just like in laboratory animals, when you take food away, they often turn to other substances,” Dr. Bulik said.

Careful attention to patterns and changes in patients' substance abuse can offer important insight when tracking their eating disorder, and vice versa. It can also help in the prediction or prevention of relapse.

As an example, she described a person who may have gained control of her eating disorder but not her alcohol abuse. Because alcohol disinhibits appetite, it could trigger binge eating that could trigger a relapse of the eating disorder. Similarly, if a patient is unable to decrease her nicotine consumption, this could be an indication that her eating disorder is not well controlled.

“We need to focus on integrated treatments where we are dealing with both things at the same time, looking at how they interrelate, understanding what some of the overarching integrators might be, and exploring how substances can influence relapse,” Dr. Bulik said.

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

LONDON — The risk of adhesion-related readmission to the hospital after gynecologic surgery is highest among women whose surgery involves adhesiolysis, a finding that highlights the importance of adhesion prevention rather than removal, investigators reported.

In a poster presentation at the annual congress of the International Society for Gynecologic Endoscopy, Adrian Lower, M.D., and associates outlined their previous findings from the first Surgical and Clinical Adhesion Research (SCAR) study: 34% of patients experience at least one adhesion-related readmission (ARR) within 10 years of undergoing laparotomy.

The SCAR-2 study, which assessed only gynecology patients, found similar risks of ARR within the first 4 years of either laparotomy or laparoscopy, said Dr. Lower, a consultant gynecologist at St. Bartholomew's Hospital, London.

Now, results of the SCAR-3 study suggest that among women undergoing laparoscopic gynecologic procedures, either adhesiolysis, or a history of a previous laparotomy are the two greatest risk factors for ARR, he said.

SCAR-3 analyzed the medical records of 6,276 patients who had undergone laparoscopic gynecologic procedures (excluding sterilizations) from 1996 to 1997.

Diagnoses at the time of surgery included endometriosis (18%), inflammatory disease of the female genitalia (12%), and pain (33%).

The study found an overall risk of ARR within 5 years of 2.5%; the two highest risk factors were previous laparotomy, or adhesiolysis.

Patients who had undergone laparotomy before the index laparoscopy had an overall risk of 3.5% for ARR—with procedures on the fallopian tubes or ovaries presenting higher risk (3.9%), compared with hysterectomy (1.8%).

And patients who received adhesiolysis during a laparoscopic procedure had the highest risk of ARR at 6.8%.

LONDON — The risk of adhesion-related readmission to the hospital after gynecologic surgery is highest among women whose surgery involves adhesiolysis, a finding that highlights the importance of adhesion prevention rather than removal, investigators reported.

In a poster presentation at the annual congress of the International Society for Gynecologic Endoscopy, Adrian Lower, M.D., and associates outlined their previous findings from the first Surgical and Clinical Adhesion Research (SCAR) study: 34% of patients experience at least one adhesion-related readmission (ARR) within 10 years of undergoing laparotomy.

The SCAR-2 study, which assessed only gynecology patients, found similar risks of ARR within the first 4 years of either laparotomy or laparoscopy, said Dr. Lower, a consultant gynecologist at St. Bartholomew's Hospital, London.

Now, results of the SCAR-3 study suggest that among women undergoing laparoscopic gynecologic procedures, either adhesiolysis, or a history of a previous laparotomy are the two greatest risk factors for ARR, he said.

SCAR-3 analyzed the medical records of 6,276 patients who had undergone laparoscopic gynecologic procedures (excluding sterilizations) from 1996 to 1997.

Diagnoses at the time of surgery included endometriosis (18%), inflammatory disease of the female genitalia (12%), and pain (33%).

The study found an overall risk of ARR within 5 years of 2.5%; the two highest risk factors were previous laparotomy, or adhesiolysis.

Patients who had undergone laparotomy before the index laparoscopy had an overall risk of 3.5% for ARR—with procedures on the fallopian tubes or ovaries presenting higher risk (3.9%), compared with hysterectomy (1.8%).

And patients who received adhesiolysis during a laparoscopic procedure had the highest risk of ARR at 6.8%.

LONDON — The risk of adhesion-related readmission to the hospital after gynecologic surgery is highest among women whose surgery involves adhesiolysis, a finding that highlights the importance of adhesion prevention rather than removal, investigators reported.

In a poster presentation at the annual congress of the International Society for Gynecologic Endoscopy, Adrian Lower, M.D., and associates outlined their previous findings from the first Surgical and Clinical Adhesion Research (SCAR) study: 34% of patients experience at least one adhesion-related readmission (ARR) within 10 years of undergoing laparotomy.

The SCAR-2 study, which assessed only gynecology patients, found similar risks of ARR within the first 4 years of either laparotomy or laparoscopy, said Dr. Lower, a consultant gynecologist at St. Bartholomew's Hospital, London.

Now, results of the SCAR-3 study suggest that among women undergoing laparoscopic gynecologic procedures, either adhesiolysis, or a history of a previous laparotomy are the two greatest risk factors for ARR, he said.

SCAR-3 analyzed the medical records of 6,276 patients who had undergone laparoscopic gynecologic procedures (excluding sterilizations) from 1996 to 1997.

Diagnoses at the time of surgery included endometriosis (18%), inflammatory disease of the female genitalia (12%), and pain (33%).

The study found an overall risk of ARR within 5 years of 2.5%; the two highest risk factors were previous laparotomy, or adhesiolysis.

Patients who had undergone laparotomy before the index laparoscopy had an overall risk of 3.5% for ARR—with procedures on the fallopian tubes or ovaries presenting higher risk (3.9%), compared with hysterectomy (1.8%).

And patients who received adhesiolysis during a laparoscopic procedure had the highest risk of ARR at 6.8%.

LONDON — The strongest data yet on pregnancies after uterine artery embolization suggest that the procedure poses less risk to subsequent pregnancies than was previously suspected, according to British researchers.

“It would be scientifically invalid to suggest that no patient wishing to become pregnant in the future should undergo uterine artery embolization [UAE],” said Woodruff J. Walker, M.D., who presented the data at the annual congress of the International Society for Gynecologic Endoscopy.

“This evidence suggests the risks of pregnancy after UAE are less than first feared,” commented Franklin D. Loffer, M.D., medical director and executive vice president of AAGL, an association formerly known as the American Association of Gynecologic Laparoscopists.

“This is a very large, long series. And it is the type of information that, as it accumulates, sets opinions,” he told this newspaper.

Dr. Walker, an interventional radiologist at Royal Surrey County Hospital in Guildford, England, also presented prospective long-term follow-up data on uterine artery embolization (UAE). The prospective study included 174 women who were followed for 5ndash;7 years after undergoing UAE for symptomatic fibroids.

Out of 98 patients who expressed a desire for future pregnancy, 42 reported a total of 53 pregnancies making this the largest series of post-UAE pregnancies from a single center worldwide, Dr. Walker said.

One pregnancy was conceived through in vitro fertilization. The rest were spontaneous conceptions. In addition to 29 live births, there were 4 ongoing pregnancies, 13 miscarriages, 4 terminations, 1 ectopic pregnancy, and 1 stillbirth due to a knotted umbilical cord. There also was another stillbirth resulting from uterine rupture through the cesarean scar in a woman with her second pregnancy after UAE.

The spontaneous miscarriage rate in this series was 24.5%, said Dr. Walker, which is within the normal range for women of this age. The mean age of women who miscarried was 42; the mean age of women with live births was 36.

Two terminations were chosen for social reasons, while one was chosen because of a diagnosis of trisomy 21. Another one was chosen because of abnormal growth at 15 weeks' gestation.

There were four categories of obstetric complications that occurred more frequently in the study group than the normal obstetric population of the same age, Dr. Walker said. (See table.)

Eighteen women had experienced subfertility ranging from 18 months to 8 years before undergoing UAE. Eleven of those women reported successful pregnancies after the procedure.

There was a high cesarean section rate —22 out of the 29 live births. Twelve of the sections were elective, and the other 10 were emergency, 4 of which were performed after attempted vaginal delivery.

According to Dennis Hidlebaugh, M.D., a gynecologic surgeon at Cleveland Clinic Florida, Naples, the pregnancy results after UAE in this study are reassuring.

“They seem no different from any other results in a slightly older population,” he told this newspaper. “In all, this study helps define better outcomes and risks so that patients can be better counseled.”

The one patient whose second post-UAE pregnancy resulted in uterine rupture through her C-section scar “might imply that prior C-section might increase the risk,” Dr. Hidlebaugh said.

In terms of patient satisfaction after UAE, 75% of the 174 women experienced a normalization of heavy menstrual flow, Dr. Walker said.

Eighty-seven percent of women said they would recommend the procedure to others, 61% said they were satisfied with the procedure, and 85% reported an improved quality of life.

Persistent vaginal discharge after UAE occurred in 5.2% of the women.

Among those women for whom the procedure did not reduce symptoms adequately, five subsequently underwent hysteroscopic resection; one, a laparoscopic myomectomy; and nine, hysterectomies.

Ovarian failure remains a potential risk of UAE, but it is rare—reported in 7.6% of women, although only one of these patients was under age 45, Dr. Walker said.

“In older patients, there is some suggestion that UAE can bring on menopause earlier,” he said. In a larger series of 1,200 women, 5 women younger than 45 years have experienced ovarian failure, although 2 had predisposing factors, he added.

In conclusion, Dr. Walker noted that patients with failed hysteroscopic or laparoscopic myomectomies or those with large submucous or numerous interstitial fibroids can be successfully treated with UAE and should be offered this option, even if they desire future fertility.

LONDON — The strongest data yet on pregnancies after uterine artery embolization suggest that the procedure poses less risk to subsequent pregnancies than was previously suspected, according to British researchers.

“It would be scientifically invalid to suggest that no patient wishing to become pregnant in the future should undergo uterine artery embolization [UAE],” said Woodruff J. Walker, M.D., who presented the data at the annual congress of the International Society for Gynecologic Endoscopy.

“This evidence suggests the risks of pregnancy after UAE are less than first feared,” commented Franklin D. Loffer, M.D., medical director and executive vice president of AAGL, an association formerly known as the American Association of Gynecologic Laparoscopists.

“This is a very large, long series. And it is the type of information that, as it accumulates, sets opinions,” he told this newspaper.

Dr. Walker, an interventional radiologist at Royal Surrey County Hospital in Guildford, England, also presented prospective long-term follow-up data on uterine artery embolization (UAE). The prospective study included 174 women who were followed for 5ndash;7 years after undergoing UAE for symptomatic fibroids.

Out of 98 patients who expressed a desire for future pregnancy, 42 reported a total of 53 pregnancies making this the largest series of post-UAE pregnancies from a single center worldwide, Dr. Walker said.

One pregnancy was conceived through in vitro fertilization. The rest were spontaneous conceptions. In addition to 29 live births, there were 4 ongoing pregnancies, 13 miscarriages, 4 terminations, 1 ectopic pregnancy, and 1 stillbirth due to a knotted umbilical cord. There also was another stillbirth resulting from uterine rupture through the cesarean scar in a woman with her second pregnancy after UAE.

The spontaneous miscarriage rate in this series was 24.5%, said Dr. Walker, which is within the normal range for women of this age. The mean age of women who miscarried was 42; the mean age of women with live births was 36.

Two terminations were chosen for social reasons, while one was chosen because of a diagnosis of trisomy 21. Another one was chosen because of abnormal growth at 15 weeks' gestation.

There were four categories of obstetric complications that occurred more frequently in the study group than the normal obstetric population of the same age, Dr. Walker said. (See table.)

Eighteen women had experienced subfertility ranging from 18 months to 8 years before undergoing UAE. Eleven of those women reported successful pregnancies after the procedure.

There was a high cesarean section rate —22 out of the 29 live births. Twelve of the sections were elective, and the other 10 were emergency, 4 of which were performed after attempted vaginal delivery.

According to Dennis Hidlebaugh, M.D., a gynecologic surgeon at Cleveland Clinic Florida, Naples, the pregnancy results after UAE in this study are reassuring.

“They seem no different from any other results in a slightly older population,” he told this newspaper. “In all, this study helps define better outcomes and risks so that patients can be better counseled.”

The one patient whose second post-UAE pregnancy resulted in uterine rupture through her C-section scar “might imply that prior C-section might increase the risk,” Dr. Hidlebaugh said.

In terms of patient satisfaction after UAE, 75% of the 174 women experienced a normalization of heavy menstrual flow, Dr. Walker said.

Eighty-seven percent of women said they would recommend the procedure to others, 61% said they were satisfied with the procedure, and 85% reported an improved quality of life.

Persistent vaginal discharge after UAE occurred in 5.2% of the women.

Among those women for whom the procedure did not reduce symptoms adequately, five subsequently underwent hysteroscopic resection; one, a laparoscopic myomectomy; and nine, hysterectomies.

Ovarian failure remains a potential risk of UAE, but it is rare—reported in 7.6% of women, although only one of these patients was under age 45, Dr. Walker said.

“In older patients, there is some suggestion that UAE can bring on menopause earlier,” he said. In a larger series of 1,200 women, 5 women younger than 45 years have experienced ovarian failure, although 2 had predisposing factors, he added.

In conclusion, Dr. Walker noted that patients with failed hysteroscopic or laparoscopic myomectomies or those with large submucous or numerous interstitial fibroids can be successfully treated with UAE and should be offered this option, even if they desire future fertility.

LONDON — The strongest data yet on pregnancies after uterine artery embolization suggest that the procedure poses less risk to subsequent pregnancies than was previously suspected, according to British researchers.

“It would be scientifically invalid to suggest that no patient wishing to become pregnant in the future should undergo uterine artery embolization [UAE],” said Woodruff J. Walker, M.D., who presented the data at the annual congress of the International Society for Gynecologic Endoscopy.

“This evidence suggests the risks of pregnancy after UAE are less than first feared,” commented Franklin D. Loffer, M.D., medical director and executive vice president of AAGL, an association formerly known as the American Association of Gynecologic Laparoscopists.

“This is a very large, long series. And it is the type of information that, as it accumulates, sets opinions,” he told this newspaper.

Dr. Walker, an interventional radiologist at Royal Surrey County Hospital in Guildford, England, also presented prospective long-term follow-up data on uterine artery embolization (UAE). The prospective study included 174 women who were followed for 5ndash;7 years after undergoing UAE for symptomatic fibroids.

Out of 98 patients who expressed a desire for future pregnancy, 42 reported a total of 53 pregnancies making this the largest series of post-UAE pregnancies from a single center worldwide, Dr. Walker said.

One pregnancy was conceived through in vitro fertilization. The rest were spontaneous conceptions. In addition to 29 live births, there were 4 ongoing pregnancies, 13 miscarriages, 4 terminations, 1 ectopic pregnancy, and 1 stillbirth due to a knotted umbilical cord. There also was another stillbirth resulting from uterine rupture through the cesarean scar in a woman with her second pregnancy after UAE.

The spontaneous miscarriage rate in this series was 24.5%, said Dr. Walker, which is within the normal range for women of this age. The mean age of women who miscarried was 42; the mean age of women with live births was 36.

Two terminations were chosen for social reasons, while one was chosen because of a diagnosis of trisomy 21. Another one was chosen because of abnormal growth at 15 weeks' gestation.

There were four categories of obstetric complications that occurred more frequently in the study group than the normal obstetric population of the same age, Dr. Walker said. (See table.)

Eighteen women had experienced subfertility ranging from 18 months to 8 years before undergoing UAE. Eleven of those women reported successful pregnancies after the procedure.

There was a high cesarean section rate —22 out of the 29 live births. Twelve of the sections were elective, and the other 10 were emergency, 4 of which were performed after attempted vaginal delivery.

According to Dennis Hidlebaugh, M.D., a gynecologic surgeon at Cleveland Clinic Florida, Naples, the pregnancy results after UAE in this study are reassuring.

“They seem no different from any other results in a slightly older population,” he told this newspaper. “In all, this study helps define better outcomes and risks so that patients can be better counseled.”

The one patient whose second post-UAE pregnancy resulted in uterine rupture through her C-section scar “might imply that prior C-section might increase the risk,” Dr. Hidlebaugh said.

In terms of patient satisfaction after UAE, 75% of the 174 women experienced a normalization of heavy menstrual flow, Dr. Walker said.

Eighty-seven percent of women said they would recommend the procedure to others, 61% said they were satisfied with the procedure, and 85% reported an improved quality of life.

Persistent vaginal discharge after UAE occurred in 5.2% of the women.

Among those women for whom the procedure did not reduce symptoms adequately, five subsequently underwent hysteroscopic resection; one, a laparoscopic myomectomy; and nine, hysterectomies.

Ovarian failure remains a potential risk of UAE, but it is rare—reported in 7.6% of women, although only one of these patients was under age 45, Dr. Walker said.

“In older patients, there is some suggestion that UAE can bring on menopause earlier,” he said. In a larger series of 1,200 women, 5 women younger than 45 years have experienced ovarian failure, although 2 had predisposing factors, he added.

In conclusion, Dr. Walker noted that patients with failed hysteroscopic or laparoscopic myomectomies or those with large submucous or numerous interstitial fibroids can be successfully treated with UAE and should be offered this option, even if they desire future fertility.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said. But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” they noted (Ann. Intern. Med. 2005;142:173–81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant. They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations. They found limited evidence that screening may have led to interventions for low bone density. A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with participants whose bone densities were above average. In addition, more screened than nonscreened participants began using multivitamins.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said. But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” they noted (Ann. Intern. Med. 2005;142:173–81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant. They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations. They found limited evidence that screening may have led to interventions for low bone density. A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with participants whose bone densities were above average. In addition, more screened than nonscreened participants began using multivitamins.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said. But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” they noted (Ann. Intern. Med. 2005;142:173–81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant. They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations. They found limited evidence that screening may have led to interventions for low bone density. A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with participants whose bone densities were above average. In addition, more screened than nonscreened participants began using multivitamins.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

Children vaccinated for MMR who present with mumps-like illnesses have other identifiable viral etiologies about 14% of the time, according to results of a Finnish study.

“When one is trying to establish the cause of mumps-like symptoms in a patient, it would be worthwhile to test at least for antibodies to EBV [Epstein-Barr virus] and the parainfluenza viruses, if not for antibodies to other viruses as well,” wrote Irja Davidkin, Ph.D., and colleagues from the National Public Health Institute in Helsinki (J. Infect. Dis. 2005;191:719–23).

“An attempt to verify the etiology of mumps-like diseases is important for active surveillance in a population in which mumps is no longer endemic and also for evaluation of the success of an MMR vaccination program,” they noted.

The study analyzed frozen serum samples from 601 children and adolescents who had reported mumps-like illness but in whom mumps had been ruled out. Their symptoms usually included swelling of the parotid gland and low-grade fever.

A previous study of 848 patients with mumps-like symptoms, which included the 601 non-mumps patients, had confirmed mumps in 2% (17) of cases, while inadequate sample collection or storage accounted for the remaining 230 cases.

Among the 601 non-mumps cases, antibody testing revealed an acute viral infection in 84 (14%) patients; the remaining patients could not be diagnosed.

EBV was the most commonly identified viral infection, occurring in 7% of patients, which was half of the diagnosed group. Parainfluenza types 1, 2, and 3 made up another 4% of the diagnosable cases, adenovirus was seen in 3% of cases, and enterovirus was seen in 2% of cases. Additionally, 0.5% of patients were diagnosed with parvovirus, and human herpesvirus was seen in 4% of a subgroup of children under 4 years old.

A total of 14 patients were diagnosed with two concomitant viral infections, and 2 patients had three diagnoses.

The authors noted that although adenovirus infection associated with parotitis has been previously reported only in HIV-positive patients, this study indicates it should be considered in the differential diagnosis for mumps-like symptoms in otherwise healthy children and adolescents.

Children vaccinated for MMR who present with mumps-like illnesses have other identifiable viral etiologies about 14% of the time, according to results of a Finnish study.

“When one is trying to establish the cause of mumps-like symptoms in a patient, it would be worthwhile to test at least for antibodies to EBV [Epstein-Barr virus] and the parainfluenza viruses, if not for antibodies to other viruses as well,” wrote Irja Davidkin, Ph.D., and colleagues from the National Public Health Institute in Helsinki (J. Infect. Dis. 2005;191:719–23).

“An attempt to verify the etiology of mumps-like diseases is important for active surveillance in a population in which mumps is no longer endemic and also for evaluation of the success of an MMR vaccination program,” they noted.

The study analyzed frozen serum samples from 601 children and adolescents who had reported mumps-like illness but in whom mumps had been ruled out. Their symptoms usually included swelling of the parotid gland and low-grade fever.

A previous study of 848 patients with mumps-like symptoms, which included the 601 non-mumps patients, had confirmed mumps in 2% (17) of cases, while inadequate sample collection or storage accounted for the remaining 230 cases.

Among the 601 non-mumps cases, antibody testing revealed an acute viral infection in 84 (14%) patients; the remaining patients could not be diagnosed.

EBV was the most commonly identified viral infection, occurring in 7% of patients, which was half of the diagnosed group. Parainfluenza types 1, 2, and 3 made up another 4% of the diagnosable cases, adenovirus was seen in 3% of cases, and enterovirus was seen in 2% of cases. Additionally, 0.5% of patients were diagnosed with parvovirus, and human herpesvirus was seen in 4% of a subgroup of children under 4 years old.

A total of 14 patients were diagnosed with two concomitant viral infections, and 2 patients had three diagnoses.

The authors noted that although adenovirus infection associated with parotitis has been previously reported only in HIV-positive patients, this study indicates it should be considered in the differential diagnosis for mumps-like symptoms in otherwise healthy children and adolescents.

Children vaccinated for MMR who present with mumps-like illnesses have other identifiable viral etiologies about 14% of the time, according to results of a Finnish study.

“When one is trying to establish the cause of mumps-like symptoms in a patient, it would be worthwhile to test at least for antibodies to EBV [Epstein-Barr virus] and the parainfluenza viruses, if not for antibodies to other viruses as well,” wrote Irja Davidkin, Ph.D., and colleagues from the National Public Health Institute in Helsinki (J. Infect. Dis. 2005;191:719–23).

“An attempt to verify the etiology of mumps-like diseases is important for active surveillance in a population in which mumps is no longer endemic and also for evaluation of the success of an MMR vaccination program,” they noted.

The study analyzed frozen serum samples from 601 children and adolescents who had reported mumps-like illness but in whom mumps had been ruled out. Their symptoms usually included swelling of the parotid gland and low-grade fever.

A previous study of 848 patients with mumps-like symptoms, which included the 601 non-mumps patients, had confirmed mumps in 2% (17) of cases, while inadequate sample collection or storage accounted for the remaining 230 cases.

Among the 601 non-mumps cases, antibody testing revealed an acute viral infection in 84 (14%) patients; the remaining patients could not be diagnosed.

EBV was the most commonly identified viral infection, occurring in 7% of patients, which was half of the diagnosed group. Parainfluenza types 1, 2, and 3 made up another 4% of the diagnosable cases, adenovirus was seen in 3% of cases, and enterovirus was seen in 2% of cases. Additionally, 0.5% of patients were diagnosed with parvovirus, and human herpesvirus was seen in 4% of a subgroup of children under 4 years old.

A total of 14 patients were diagnosed with two concomitant viral infections, and 2 patients had three diagnoses.

The authors noted that although adenovirus infection associated with parotitis has been previously reported only in HIV-positive patients, this study indicates it should be considered in the differential diagnosis for mumps-like symptoms in otherwise healthy children and adolescents.