Acta Obstétrica e Ginecológica Portuguesa

Cervical cancer screening: turning point?

Evaluation on portuguese women contraceptive practice

Background: The study about evaluation of the contraceptive practices in Portugal is a cross-sectional survey that evaluated women's contraceptive choices and how they get information and advice about sexuality and contraception. Methods: Women aged between 15 and 49 years completed an anonymous questionnaire with 21 questions, which included open and closed questions on information and use of contraceptive methods. The results were analyzed and compared with the results of the survey performed in 2005 by the Portuguese Gynecology Society. Results: Information about sexuality and contraception at school is acknowledged by 70% of the younger women. For this group other sources of information about contraception are friends, 46,1% and internet 45,9%. On the other side women older than 30 years get information on contraception mainly through family doctors and gynecologists. 94% of sexuality active women use contraception, this percentage is significantly higher than the one observed in 2005, 75,4%. Contraceptive pill remains as the preferred method for Portuguese women although its use decreased from 70,4% to 58% of the women between 2005 and 2015. On the other hand the preference for methods independent from the users, long-acting reversible contraception (LARCs), has significantly increased. Women still maintain a high rate of forgetfulness for the pill and considering this fact the use of emergency contraception is still low. Use of contraception is beneficial for quality of life according to 81% of women in this study. Conclusions: Portuguese women are in general well informed and get an easy access to contraceptive methods. The amount of sexually active women using contraception has increased in ten years and almost achieves 100%. Contraceptive pill is the number one choice for more than 50% of women but the use of LARCs is steadily increasing

Pregnancy in chronic kidney disease: from peritoneal dialysis to hemodialysis

Overview and Aims: pregnancy in women with chronic kidney disease (CKD), particularly in terminal CKD, remains a rare event. There are scarce reports of pregnancy in women undergoing peritoneal dialysis. Our study aims to evaluate the outcomes of pregnancies in women with CKD diagnosed at Hospital São João during the study period. Study design: retrospective case series. Population: pregnant women with chronic kidney disease diagnosed between January 2005 and December 2013. Methods: pregnancies in women with severe CKD (GFR <30mL in/1.73m2) were identified by using hospital electronic platforms with evaluation of maternal and fetal outcomes. Results: during the study period 4 cases of pregnancy in women with CKD were identified, including one of a woman in peritoneal dialysis prior to pregnancy - case 1. Case 1 progressed to hemodialysis at 17 weeks (due to haemoperitoneum subsequent to trauma by the peritoneal dialysis catheter) and had an eutocic late preterm delivery at 35 weeks. Case 2 began hemodialysis at 22 weeks, and was submitted to urgent cesarean section at 29 weeks. Case 3 started hemodialysis at 21 weeks, having also undergone urgent cesarean section at 31 weeks. Case 4 began hemodialysis at 21 weeks, presenting with an episode of hepatotoxicity secondary to darbopoietin at 26 weeks. Delivery occurred by Caesarean section at 32 weeks. Conclusion: despite the high fetal morbidity documented, with the strategies adopted there was no fetal or neonatal mortality. The monitoring of these pregnant in specialized consultation favored the positive outcomes.

Menopause hormone therapy and breast cancer: a case series

Overview and Aims: Menopause hormone therapy (MHT) has been associated with mammographic changes and increased risk of breast cancer. The aim of this study was to evaluate the frequency of mammographic changes and breast cancer in women undergoing MHT. Population and Methods: Retrospective study with a series of women undergoing MHT between January 2009 and December 2013 divided in three groups: unopposed estrogen (E, n = 28), combined estrogen plus progestin (E+P, n = 118) or tibolone (n = 98). Primary outcome was the frequency of breast cancer. Secondary outcomes included: frequency of mammographic changes, need of mammary biopsy and the association of those outcomes with first-degree family history of breast cancer. Results: Among the 244 women included, the mammographic reports of 12% (30/244) revealed BIRADS ≥3, and in 7 of these cases a breast biopsy was performed. There were two cases of breast cancer in patients undergoing E+P and tibolone, respectively. Mammographic breast density was increased in 19% of women (46/244), with no statistically significant difference among the three groups. There was a statistically significant higher frequency of increased density on mammographies of women with first-degree family history of breast cancer compared to those without family history (8/20 vs. 38/224; p = 0,03). Conclusions: In our sample the increased density after MHT was more significant for women with family history of breast cancer.

"See and treat" in women with high-grade squamous intraepithelial lesion: Hospitais da Universidade de Coimbra (HUC) outcomes: suitable approach?

Introduction: The "see and treat" approach is an immediate diagnosis and treatment of cervical intraepithelial neoplasia (CIN) using loop electrosurgical excision procedure (LEEP). However, this approach has some degree of overtreatment rate, which is defined as a negative LEEP histology. This study was undertaken to evaluate the overtreatment rate of the "see and treat" approach in women with high-grade squamous intraepithelial lesion (HSIL) citology, in a tertiary care university hospital. Methods: A total of 44 women with HSIL on cervical citology undergoing colposcopy followed by LEEP, between January 2010 and March 2012, were analyzed in a tertiary center. The statistical analysis was carried out using SPSS computer software version 21. Chi-square test was used to determine the impact of age, menopausal status and colposcopic findings in the overtreatment rate. Results: During the study period, 44 women were analyzed. The mean age was 43 years. A total of 31,8% (n=14) women were postmenopausal. About 50% (n=22) had unsatisfactory colposcopic evaluation. The other 22 colposcopies revealed 18 cases of high grade lesions (81,8%). The LEEP histopathological results were as follows: CIN 2 (34,1%;n=15), CIN 3 (29,5%;n=13), invasive cervical carcinoma (2,3%;n=1), adenocarcinoma in situ (2,3%;n=1), CIN 1 (18,2%;n=8), no CIN (11,3%;n=5) and inconclusive (2,3%;n=1). These findings indicate that a total of 68,2% women with HSIL had high-grade lesions in histology. The overtreatment rate was 13,6%. Conclusions: In our institution, the "see and treat" approach has an overtreatment rate (13,6%) slightly higher than the reported in the literature. Age, menopausal status and colposcopic findings had no statistically significant impact on the overtreatment rate. Regarding the cyto-histologic correlation in this study, it was recorded a total of 68.2 % of high-grade lesions (histologically proven) in cytology HSIL. Due to low rate of complications, the "see and treat" procedure seems to be a safe procedure.

Elective induction of labor at 39 weeks vs expectant management of pregnancy: a systematic review

Objective: We aimed to compare elective induction of labor at 39 weeks with expectant management of noncomplicated singleton pregnancies. Material and methods: We performed a systematic review and a meta-analysis with the articles which had the same methodology. Results: Regarding the cesarean section rate at 39 weeks, most studies reported an equal or lower frequency in the elective induction group. Overall, maternal and neonatal complications were not higher after elective induction, with studies associating it to a lower frequency of some adverse outcomes. However, elective induction was associated with a higher rate of shoulder dystocia, epidural use and an increase in labor duration and cost. Conclusion: Elective induction of labor at 39 weeks, when compared to expectant management, has not been associated with a significantly higher rate of caesarean sections. However, there's a lack of evidence to change the current recommendations on induction of labor.

Axillary lymph node dissection: still a necessary procedure?

Sentinel lymph node biopsy (SLNB) is the gold standard procedure for breast cancer staging and axillary lymph node dissection (AD) is recommended when metastasis are found. Two recent practice-changing studies altered this paradigm. They brought into discussion old unanswered questions, such as the impact of AD on morbidity, survival and choice of adjuvant therapy as well as new questions, like the role of radiotherapy and the omission of AD after positive SLNB. The authors reviewed the literature focusing on these issues and concluded that AD after positive SLNB can be omitted in selected cases.

Trends in the treatment of genital prolapse: a review of apical suspension techniques

Genital prolapse is a highly prevalent disorder in women with negative impact in quality of life and sexual function. For uterovaginal prolapse, surgical repair may or may not include a hysterectomy, but the reestablishment of the vaginal apical support is always mandatory to ensure long-term effectiveness. Choosing the most appropriate surgical procedure should take into consideration many factors, such as the location of the anatomical defects, the severity of symptoms, the woman's level of activity or concerns regarding the treatment's durability. In this article we review data that can help to guide decisions when treating women with apical genital prolapse.

Caudal regression syndrome: a case of early prenatal diagnosis without maternal diabetes

Caudal regression syndrome (CRS) is a rare and severe syndrome in which a segment of the lumbo sacral spine and spinal cord fails to develop. CRS is generally diagnosed at prenatal assessment, commonly in the late second trimester. The pathogenesis is still unclear, however its relationship to maternal diabetes is well established. The authors report a case of CRS diagnosed at 17 weeks of gestation.

Benign metastasizing leiomyoma: pulmonary involvement from an uterine fibroid

Benign Metastasizing Leiomyoma (BML) is a rare disorder in which uterine fibroids metastasize to distant sites. We present a case of a 57-year-old postmenopausal woman under hormone therapy with a previous total hysterectomy for uterine fibroids that performed chest radiography, for a history of weight loss, that showed multiple bilateral pulmonary nodules. The histological examination of these nodules revealed a morphological and immunohistochemical profile consistent with the diagnosis of pulmonary BML (supported by a history of primary uterine leiomyoma). The patient started treatment with tamoxifen, remaining asymptomatic and with stable pulmonary lesions.

Endometriosis: medical treatment Portuguese consensus recommendation

Overview and aims: This article summarises the Portuguese endometriosis consensus elaborated in order to adapt to our population the consensus documents published in the literature. Endorsed by the Portuguese Society of Gynaecology, we established recommendations that provide guidance to our medical society to better decision making concerning the assistance of patients with endometriosis, to improve diagnosis and to optimize management. We expose here a short version of the second section of the guidelines, addressing the medical treatment of this disease. Study design and Methods: The European Society of Human Reproduction and Embryology (ESHRE) guideline for the diagnosis and treatment of endometriosis (2014) was the reference paper for these clinical recommendations in endometriosis. A group of experts in the field performed a thorough systematic search of the publications between January 2012 up to December 2014 and a quality assessment of the included papers. A consensus meeting with all members of the guidelines developing group reached the final version of the recommendations. Conclusions: The present clinical practice guidelines on endometriosis may improve the medical management in endometriosis-associated pain.