Snippets

DOI: 10.1111/j.1471-0528.2011.03075.x
www.bjog.org

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Hysterectomy trends

Single port versus multiple ports

Although medical management and endometrial treatments offer alternatives to surgery, hysterectomy remains a highly popular
form of treatment for uterine pathology with
very high satisfaction levels. Moves towards
the vaginal route or laparoscopic procedures
are appearing in the literature with welldocumented advantages in respect of less
tissue trauma and shorter hospital stays.

Laparoscopically assisted vaginal hysterectomies can be carried out using single or

multiple port techniques. The single-port
method uses a two-channel scope inserted
peri-umbilically whereas the multiport
method uses two or more instrument access
points transabdominally. In a randomised
trial comparing the two approaches, Chen
et al. (Obstet Gynecol 2011;117:90612)
found no differences in operating time,
blood loss, time to first flatus, complications or length of hospital stay between the
two groups but there was a difference in
the immediate postoperative pain experienced.
The single-port group had significantly
less pain at 24 and 48 hours and women
required less analgesia than those undergoing the multiport procedure.

Day-cases
Women undergoing supracervical laparoscopic hysterectomy either as a day-case or
as an overnight stay postoperatively were
asked to rate their experiences. The women
were randomised to their length of stay and
judged both options similarly in terms of
convenience
and
satisfactionhowever,
those allocated to being day-cases reported
an inferior quality of life on day 2 postoperatively (Kisic-Trope et al. AJOG 2011;204:
307.e18).

Complication of total or
supracervical procedures
A large series (over 1000) of laparoscopic
hysterectomies were scrutinised to see if
total or supracervical procedures resulted in
more re-admissions or complications. Taking the group as a whole the following statistics emerged: about half of the women
were discharged the same day as the operation, about half had the total and half the
supracervical procedure, the median uterine
weight was 155g, blood loss was 70ml and
the operating time was 150 minutes.
Complication rates of incision site infection, cuff dehiscence or vaginal bleeding were
low, as were re-admission rates, being < 1%
in the first 48 hours and cumulative rates
around 4% at 3 and 12 months. These results
lead the authors to conclude that both total
and supracervical approaches seldom have
complications when handled laparoscopically and early discharge is acceptable with
few readmissions (Perron-Burdick et al.
Obstet Gynecol 2011;117:113641).

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Changing trends
There are strong trends towards a laparoscopic rather than an open abdominal
approach to hysterectomy in well-resourced
settings. This is confirmed in audits from
the Brigham and Womens hospital in Boston comparing the two techniques in 2006
and 2009. Roughly 1000 hysterectomies
were performed each year but the number
carried out through open laparotomy
decreased from two-thirds to one-third and
those done laparoscopically increased from
18 to 46% (Jonsdottir et al. Obstet Gynecol
2011;117:1142-9).
During these time-frames intraoperative
complications dropped from 7 to 4%
whereas minor postoperative problems were
reduced from 18 to 6%. Operative costs
were increased but there was no significant
change in the womens total mean financial
charges in hospital.

progestogens postmenopausally. Part of the

study looked at giving conjugated equine
estrogens (CEE) to hysterectomised women
and it is this group who have been followed
up by LaCroix and colleagues (JAMA
2011;305:130514).
Nearly 80% of these women continued
to be observed to see if on-treatment
trends were sustained after they ceased taking CEE or placebo. What the researchers
found was that 5 years of estrogen-only
therapy did not have any ongoing effects
on coronary heart disease, incidence of
deep vein thrombosis, stroke, hip fracture,
colorectal cancer or overall mortality. The
initial decreased risk of breast cancer, however, did persist.
They confirmed that estrogens given for
the first time to women well past their menopause is not a good idea whereas CEE-only
taken by younger women (in their fifties)
after hysterectomy does convey some advantages if taken for 5 years and has no
rebound disadvantages when stopped. The
reduced risk of breast cancer in CEE-only
takers in this study remains an enigma and
the cardiovascular benefits in the younger
group warrant further investigation.
Again the WHI trial does not settle the
argument as the number of young hysterectomised women receiving CEE-only was
not large plus the fact that the median
duration of full compliance was not optimal. These data cannot counter the conclusion that long-term estrogen-only or
combined estrogen with progesterone
increase the risk of breast cancer as
accepted by the International Agency for
Research on Cancer (Jungheim and Colditz
JAMA 2011;305:13545). The WHI followup does not demonstrate any major harm
or benefit swings so the debate devolves to
personal choices between the woman and
her doctor.

Womens Health Initiative estrogen

replacement follow-up
The Womens Health Initiative (WHI)
hormone trial published in 2004, had a
profound effect on the use of estrogens and

Hot flush duration

It appears that hot flushes endure longer
than is generally accepted. The notion of

2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

Snippets

5 years of moderate to severe flushes seems

to be an underestimate according to a study
by Freeman et al. who conducted in-person
interviews with their clients over 15 years
(Obstet Gynecol 2011;117:10951104).
The mean age of onset was 4549 years
and the average duration was 10 years. The
longest duration occurred when the flushes
started in the early transition stage of the
menopause when they lasted 11 or more
years. If they commenced in the late transition stage the duration was about 4 years.
Being black or having an increased body
mass index were aggravating factors. Overall it seems we should widen the normal
time-range over which flushes occur.

Are calcium supplements safe?

As people live longer, osteoporosis will be a
more prevalent disorder. It is debilitating
and a wide range of recommendations are
put forward to attenuate its impactthe
most sensible of which are a healthy diet
and lifestyle. But there are vociferous proponents of medications and supplements to
stave off the ravages of bone loss as well as
those who warn against their use.
In those with osteoporosis, treatment
with bisphosphonates plus calcium and
vitamin D reduces mortality by one-quarter
in men and by one-third in women but
caveats concerning unusual hip fractures
and other skeletal anomalies do remind us
that no drugs are free of adverse effects.
Of course for women there are estrogens
and their cousins, the selective estrogen
receptor modulators, to protect bone mineral density and long-term trials may yet
prove them to be the most effective.
Calcium plus vitamin D supplements are
coming in for close scrutiny because early
observational trials suggest an increased risk
of myocardial infarction and stroke with
their use. The latest data presented by
Bolland et al. from New Zealand (BMJ
2011;342:d2040) appear to confirm the risk
by the meta-analysis of trials involving
29 000 participants with myocardial infarction chances rising 25% and stroke by 15%;

however an editorial by Abrahamsen and

Sahota (BMJ 2011;342:d2080) says the evidence is insufficient to draw conclusions of
clear risk. It seems that the widespread use
of calcium, with or without vitamin D, is
not a panacea for old people and certainly
should not be dished out without good
reason.

Caesarean section wound closure

It is surprising that there are not more trials comparing methods of wound closure
for caesarean section incisions. One would
have thought that obstetric units would
gather outcome data routinely but maybe it
is one of those areas where strong individual beliefs hold sway. Clay et al. (AJOG
2011;204:37883) performed a meta-analysis of trials comparing staples with subcuticular sutures and found that although
staples took about 5 minutes off the operating time they were associated with higher
rates of wound dehiscence and complication rates. Unsurprisingly, they call for further studies.
While on the subject of caesarean section
wounds, it seems that antibiotic cover may
need to be adjusted to reach minimal
inhibitory concentrations in obese women.
Pevzner et al. (Obstet Gynecol 2011;117:
87782) looked at the pharmokinetics of
2 g cefazolin given 3060 minutes preoperatively, at the beginning and the end of the
procedure and found differences in tissue
levels in women of normal body mass
index, obese women and morbidly obese
women.
Generally, the higher the BMI, the lower
the antibiotic levels within the skin adipose
tissue, which suggested sufficient coverage
for Gram-positive cocci but not for Gramnegative rods. The authors advise staff to
reconsider their caesarean section antimicrobial coverage policies in the light of
their research.

progestogen. Two popular progestogens are

levonorgestrel and drospirenone and OCs
containing them have outstanding pregnancy prevention records so preferences are
made on the benefits and risks of their
adverse effectsnot on their primary efficacy. Some of the benefits claimed, particularly for drospirenone-containing pills, are
improvements in acne and the premenstrual dysphoric disorder which affects
about 5% of women.
Drospirenone is derived from spironolactone and has anti-androgenic and antimineralocorticoid properties, which may
offer advantages over levonorgestrel that
women would welcome, but questions have
been raised over rates of venous thromboembolism. Compared with early versions of
OCs, the modern pills are remarkably safe
in this regard with the most recent data
confirming their safety record.
Two studies (Jick and Hernandez BMJ
2011;342:d2151 and Parkin et al. BMJ
2011;342:d2139) both show very low rates
of non-fatal venous thromboembolism in
low-dose pill usersof the order of 1030
per 100 000 woman-years. The drospirenone risk was two or three times greater
than the levonorgestrel risk but this was
not significant statistically and considerably
less than the risk during or after pregnancy.
The data for these new OCs have been
accumulated over a decade and prove the
pill to be one of the most efficient and safest medications ever created.
When is our speciality going to stand up
and be counted on this issue? When are we
going to say that OCs should be available
over the counter without prescription?
Any risk:benefit ratio of OCs versus a
pregnancy, in the language of the generation
who would benefit most, is a no-brainer. j

Athol Kent

Low-dose pills and clotting

Most modern low-dose oral contraceptives
(OCs) contain 30 mg ethinylestradiol plus a

These snippets are excerpts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics
and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at atholkent@
mweb.co.za or visit the website www.jassonline.com.

2011 The Author BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG

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