A contingent of South African key opinion leaders recently attended the Royal College of Obstetricians and Gynaecologists’ congress in Singapore. Read their impressions of the congress.
THE FROZEN PELVIS CONUNDRUM
Dr Johannes van Waart, a gynaecologist and obstetrician at Wijnland Fertility Clinic in Stellenbosch, reports on Prof Jacques Donnez’s innovative surgical approach to endometriosis associated frozen pelvis. Prof Donnez is head of the Department of Gynaecology at the Université Catholique de Louvain (Belgium) and is a world-renowned endometriosis endoscopic expert. Dr van Waart writes:
When confronted with a frozen pelvis due to endometriosis during a laparoscopic procedure, the fertility considerations are very often critically important. If excising the endometriosis lesions too aggressively, the fertility potential is most often markedly reduced. If the surgery is not aggressive enough, the clinical symptoms are mostly not addressed adequately. This often leaves the surgeon in a no-win situation.
If one side of the pelvis is more affected than the other by endometriosis (or endometrioma) and needs radical surgery, Prof Donnez recommended performing a fresh ovarian cortex transplant into a peritoneal pouch created (or in the anterior leaflet of the broad ligament) on the less affected side.
The ovarian cortex is cut into 4mm-5mm strips and then transplanted on the opposite/good side. This transplant site should be within the reach of the less affected functioning fimbrial end of the tube in order to facilitate the ‘pick up’ of the newly produced follicles originating (through neovascularisation) from the transplanted ovarian cortex tissue.
The optimal level of surgery can then be executed without fear of causing infertility. This ‘new’ follicle production from the transplanted cortex normally takes three to six months to start, and can be measured by tracking estadiol blood levels (and ultrasound follicle monitoring).
If both adnexa are adversely affected, this technique can still be used by utilising the peritoneal pouch approach. If a functioning tube is left, there is always a chance of spontaneous conception, otherwise in vitro fertilisation (IVF) can be offered.
Prof Donnez described two successful pregnancies achieved through IVF via this method. Both pregnancies went well and the children were born without any complications. This novel technique gives hope to patients with severe endometriosis needing extensive surgery to ensure a reasonable quality of life and also needing to maintain their fertility.
PAIN IN THE VAGINA
Dr Trudy Smith, gynaecological oncologist at the University of the Witwatersrand, reports:
Drs Colleen Stockdale and Lori Boardman of the Department of Obstetrics and Gynaecology at the University of Iowa (United States) presented their paper on the diagnosis and treatment of vulvar dermatoses, chronic conditions affecting up to one in five women.
According to the presenters, symptoms are often underreported by women. Although many vulvar dermatoses are chronic conditions that cannot be cured, it is possible to control in the majority of women. Patient education regarding vulvar hygiene and skin care is the foundation for optimal management of inflammatory vulvar dermatoses, they said.
It is extremely important that patients be made aware that aggressive hygiene may trigger or worsen the conditions.
Patients should also be informed that individual and tailored long-term maintenance are required to achieve optimal outcomes. Common presentations of vulvar dermatoses include:
- Lichen simplex chronicus: A nonscarring, chronic inflammatory disease of the skin characterised by intense pruritus that typically presents in mid to late adult life (although it may present at any age). Between 65% and 75% of patients have a history of allergic conditions (hay fever, asthma, childhood dermatitis). Lichen simplex chronicus is therefore often considered to be a localised atopic dermatitis. Patients typically note the need to scratch or rub, as well as sleep disturbance from the unrelenting pruritus and discomfort. Treatment requires a multi-targeted approach for optimal control of symptoms. Options include:
- Removal of initiating factor(s)
- Repair of the skin’s barrier function
- Reduction of inflammation
- Disruption of the itch-scratch cycle.
All areas should be addressed simultaneously, said the presenters.
- Attention to vulvar hygiene and avoidance of irritants as well as barrier protection (eg petrolatum, zinc oxide ointment) should be encouraged and reinforced
- Topical corticosteroids, typically moderate to high potency in an ointment base, can be used to reduce associated inflammation
- Systemic steroids may be necessary for severe lichen simplex chronicus (eg 40mg-80mg triamcinolone intramuscularly)
- Disruption of the itch–scratch cycle may require a combination of medications with antihistamine (eg 10mg-25mg hydroxyzine) or sedative (eg 25mg amitriptyline) properties as well as selective serotonin reuptake inhibitors (eg citalopram, fluoxetine, paroxetine, sertraline) to address both night-time and daytime itching.
- Lichen sclerosus: A chronic inflammatory disorder primarily affecting the genital and anal areas with extra genital lesions. Although lichen sclerosus may affect any age group, the typical age of onset in the fifth to sixth decades and a second age peak in pre-pubertal girls. The standard treatment remains:
- Topical corticosteroids (eg clobetasol propionate). Although less-potent topical corticosteroids are effective when used consistently, topical testosterone and progesterone applications should not be used in the management of lichen sclerosus. Although there is concern regarding long-term topical corticosteroid use, studies using a moderate or ultrapotent topical steroid for long-term maintenance therapy of vulvar lichen sclerosus did not result in steroid-induced changes or secondary infection. Recent literature supports the use of an ongoing maintenance regimen for optimal control of lichen sclerosus (eg twice-weekly application of either an ultrapotent or daily use of a moderate-strength steroid). The goal for treatment should be based on normalisation of skin colour and texture rather than the specific topical corticosteroid used.
- Lichen planus: An inflammatory mucocutaneous disorder that exhibits a wide range of appearances. Evidence suggests that lichen planus is an autoimmune disorder with a T-cell-mediated pathogenesis. The most common, yet most difficult to treat form is erosive lichen planus, which can lead to significant scarring and pain. Treatment options include:
- Topical corticosteroids are typically used for the initial treatment of genital lichen planus
- Calcineurin inhibitors are generally reserved for steroid-resistant disease
- Patients with vaginal lichen planus should also consider intravaginal steroids and vaginal dilation to prevent scarring. Hydrocortisone acetate suppositories of 25mg can be inserted intravaginally for treatment of vaginal involvement beginning nightly and then reduced to less-frequent dosing as needed (eg one to five nights weekly) for maintenance therapy
- For more extensive disease, high-dose hydrocortisone inserts may need to be compounded (eg 100mg/g or 200mg/g inserts)
- Vaginal dilators may be used to treat and prevent vaginal adhesions resulting from coaptation of inflamed mucosa
- Surgery may be required to restore the vaginal vault with the use of vaginal dilators and high dose intravaginal steroid therapy postoperatively
- Additionally, patients should be educated not to self-treat suspected yeast with over-the counter agents, because they may result in irritation and overall worsening of the symptoms.
- Psoriasis: A chronic, inflammatory skin disease that affects approximately 2% of the general population. Although isolated genital psoriasis occurs in 2%-5% of patients with psoriasis, it is often overlooked. Vulvar psoriasis occurs in patients of all ages. Psoriasis presents as well-demarcated pink plaques that can extend to the perianal skin. Unlike psoriasis located elsewhere, the classic silvery scale is absent as a result of the moist environment of the external genitalia. Treatment includes:
- Long-term management including topical steroids
- Low to medium potency topical steroids and steroid-sparing agents are often used in combination to minimise inflammation
- Second-line treatments include emollients, coal tar preparations, topical vitamin D analogs, pramoxine, and calcineurin inhibitors
- Severe vulvar psoriasis may require systemic therapy such as methotrexate, oral retinoids, or biological agents.
THE WASTED DECADE: HOW ONE HRT SCARE CAUSED NEEDLESS SUFFERING
Dr Karen Fourie, an obstetrician and gynaecologist based at the Netcare Pretoria East Hospital, reports on Dr Edward Morris’ presentation on hormone replacement therapy (HRT). Dr Morris is vice president of the RCOG and practises as an obstetrician and gynaecologist at the Norfolk University Hospital. He is also an honorary senior lecturer at the Medical School, University of East Anglia (England).
Dr Morris summarised the evidence from recent publications from Cancer Research United Kingdom dealing with preventable causes of cancer. Overweight and obesity were associated with 6.3% of all cancer in the UK with postmenopausal breast cancer and endometrial cancer being the most important in women. Also included on the list of malignancies associated with increased body mass index are adeno- and squamous carcinomas of the oesophagus. The report also mentioned that being overweight and obesity are the United Kingdom’s most preventable causes of cancer after smoking.
Dr Morris continued to address what he termed the ‘wasted decade’. According to him, one hormone replacement therapy (HRT) scare has caused thousands of women needless suffering for 10 years. The findings of the Women’s Health Institute’s report on the risks associated with HRT resulted in a steep drop in HRT treatment.
Women’s perception of risk appears to be vastly different from reality. It seems that the perceived risk of coronary heart disease in women is 4%, where the actual risk is 50%. In the same group of patients, the risk for breast cancer was perceived as 46%, while in reality it is 4%.
It seems clear that our duty as healthcare providers is to inform our patients accurately of the risks versus benefits of HRT, the different types of HRT available and the age of starting HRT versus the stated risks in order for patients to make informed decisions. According to a recent publication only 50% of patients feel that they have enough information to make an informed decision regarding HRT.
The benefits of HRT should be clearly explained, not just the relief of symptoms, but also the long-term benefits of HRT on lower genital track health, bone mineral density, cardiovascular health and mortality.
Risks of weight gain, bleeding, venous thromboembolism, stroke and ovarian and breast cancer need to be put in perspective to allow women to make informed decisions, even though explaining the risks might be difficult. Modifiable risk factors such as alcohol and obesity also need to the explained.
Dr Morris alluded to the risk of breast cancer with combined HRT (-4 per 1000 women for five years of use) and ovarian cancer (one per 1000 women for five years of use). In summary, patients need to be accurately informed regarding the risks and benefits of HRT by healthcare providers, because up to 50% seem to be getting information from other sources. We need to convey the risks and benefits in terms what will be easily assimilated by patients.
LAPAROSCOPY: MORE THAN MERE AESTHETICS?
Dr Olufemi Olarogun, an obstetrician and gynaecologist specialising in reproductive medicine, based at the Rondebosch Medical Centre in Cape Town reports on two presentations: Single port laparoscopy and robotic surgery.
In his presentation, Dr Anthony Siow described the process of single port laparoscopy (SILS). SILS is the latest and more advanced form of keyhole surgery in which major surgery is done with just one cut (of 2.5cm) at the belly button. A multichannel single incision port is placed at the belly button incision to allow multiple instruments to perform surgery within the abdomen.
The benefits include excellent aesthetic result as the single 2.5cm cut heals into an inconspicuous fold, less pain from the 2.5cm cut as compared to traditional surgery of a 10cm cut, less infection and surgical wound breakdown, less risk of blood vessels injury, less adhesion formation (post-surgery internal scaring), better fertility potential and faster recovery and shorter hospital stay. Dr Siow argues that apart from aesthetics, the procedure was better tolerated by patients and even though it should not replace straight sticks laparoscopy, there is a role for SILS.
IS THERE REALLY A PLACE FOR ROBOTIC SURGERY IN GYNAECOLOGY?
Dr Joseph Ng talked about the role of robotic surgery in gynaecology. He is a senior consultant in the Division of Gynaecologic Oncology at the National University Cancer Institute, Singapore, assistant professor with the Department of Obstetrics and Gynaecology of the Yong Loo Lin School of Medicine at the National University of Singapore and president of the Asian Society for Gynaecologic Robotic Surgery. Dr Ng is a staunch advocate for the role of robotic surgery in modern gynaecology – especially in oncology.
Although limited, a body of evidence is evolving that if the cost of disposables associated with robotic surgery is contained, the cost-beneﬁt assessment favours robotic surgery over laparotomy. It is therefore the ﬁrst viable surgical option that offers the advantages of minimally invasive surgery to women with conditions requiring complex pelvic surgery.
Women with severe endometriosis and gynaecologic cancer are the main beneﬁciaries of the introduction of robotics to gynaecologic surgery. Outcomes data suggest that women with endometriosis and gynaecologic cancer who undergo robotic surgery have shorter hospital stays, suffer less blood loss, use less analgesia and have a better overall quality of life as compared to women who underwent the necessary laparotomies for these conditions.
Robotic surgery offers women with gynaecologic conditions the necessary surgical treatment without impacting inpatient resources, recover with less morbidity and expect a more rapid return to being productive member of the society.