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Menopausal transition and incontinence

  1. Top of page
  2. Menopausal transition and incontinence
  3. Zoledronic acid and bone loss
  4. Operative delivery
  5. Robotic surgery for novices

The concept of menopausal transition stages is being more carefully studied and will no doubt be adopted into the obstetric and gynaecological lexicon. To assist clinicians understanding the terminology the following definitions are offered:

  • • 
    Premenopause—the time of regular hormonal patterns with <3 months of amenorrhoea and no menstrual irregularities in the previous year
  • • 
    Early perimenopause—<3 months of amenorrhoea with some menstrual irregularities in the previous year
  • • 
    Late perimenopause—3 to 11 months of amenorrhoea
  • • 
    Postmenopause—12 consecutive months of amenorrhoea.

The Menopausal Transition Stages are determined by history and their duration is personal to each individual. Using these terms, healthcare workers can more clearly describe the physiological changes experienced by women and a study in the USA has tracked a cohort of women annually for 6 years to help to establish the normal distribution of events. It is called the Study of Women’s Health across the Nation (SWAN) and has recruited over 3000 women with excellent (80%) retention rates over the entire trial.

Waetjun et al. (Obstet Gynecol 2009;114:989–98) report on urinary incontinence in the group with interesting results. Women report a slight increase in incontinence from the premenopause to the early menopause. The actual figures are from 16% to 18% for any incontinence.

From early to late perimenopause genuine stress incontinence decreases but urge incontinence is unchanged. From late perimenopause to postmenopause both stress and urge incontinence reporting decreases with the figure for any incontinence now at 8%.

The researchers believe that the initial increase may be the result of ‘over-reporting’ of a worrisome symptom while other untoward events are being experienced, or increasing body mass index, or the development of diabetes, the latter two being frequent accompaniments of the transition years in women in the USA. Their overall finding—that incontinence decreases significantly as a symptom through the menopause years—will be reassuring to clinical practice advisors. Factors such as being overweight and the optimal management of diabetes are modifiable, so positive steps in terms of lifestyle can be strongly reinforced.

Zoledronic acid and bone loss

  1. Top of page
  2. Menopausal transition and incontinence
  3. Zoledronic acid and bone loss
  4. Operative delivery
  5. Robotic surgery for novices

Postmenopausal women are susceptible to bone loss. There is a continuum from low bone mass, through osteopenia to osteoporosis with concomitant increasing risks of fracture. The considerable morbidity and mortality associated with such fractures makes their prevention a major public health objective and pharmacological agents offer much in the way of protection.

Estimation of the risk of fracture can be reasonably accurately calculated using the computer algorithm frax (http://www.shef.ac.uk/FRAX/) or advice can be obtained from http://www.nof.org/professionals/clinicians_guide for women who are well informed.

All management starts with prevention, which includes exercise, calcium and at least 800 IU vitamin D per day in older women and when treatment is required estrogens are of value although their long-term use is a matter of personal perspective. Bisphosphonates work but their track record for being taken consistently orally is patchy so the intravenous form—zoledronic acid—given on an annual basis is being investigated. McClung et al. (Obstet Gynecol 2009;114:999–1007) conducted a trial over 2 years matching 5 mg zoledronic acid against placebo and found unequivocal evidence of bone loss prevention for the active medication.

As the population ages, more tailored treatments will need to be devised and 12-monthly infusions appear a viable option.

Breast cancer survivors on aromatase inhibitors constitute another group at risk from bone loss. Aromatase inhibitors may prove superior to tamoxifen for recurrence prevention and regular intravenous zoledronic acid has been shown to be superior to intermittent use in bone mass preservation (32nd Annual San Antonio Breast Cancer Symposium: Abstract 4083; presented 11 December 2009). This seems promising, so formal publications are awaited with interest.

Operative delivery

  1. Top of page
  2. Menopausal transition and incontinence
  3. Zoledronic acid and bone loss
  4. Operative delivery
  5. Robotic surgery for novices

Trials involving the outcomes of labour are notoriously difficult to conduct. Apart from the problems of homogeneity and randomisation, end points of suboptimal outcomes are rare so large numbers with extended follow-up are required. Also, many pathological sequences that are attributed to the labour process have their origins well before parturition, which leads to confusion about cause and effect.

Nevertheless many observational data about mode of delivery continue to be collected and deserve careful consideration because they may contain important messages that will enable us to improve outcomes.

Operative vaginal deliveries are becoming ever rarer methods of delivery. With caesarean section rates around 30% in developed countries, there appears to be a lowered threshold to resort to abdominal delivery, resulting in almost trivial indications being sufficient to culminate in a caesarean section. There are, in addition, concerns that a failed attempt at an instrumental vaginal delivery might result in fetal damage and all its consequences, so defensive obstetrics has become a reality with concomitant ‘skills attrition’ fuelling the cycle.

To help us clarify this particular issue, there are several recent large studies looking at the risks associated with failed operative vaginal deliveries. Alexander et al. (Obstet Gynecol 2009;114:1017–22) showed that, provided the fetal heart rate tracing was normal (not abnormal or even nonreassuring) then an attempt at an instrumental delivery, followed by a caesarean section was not detrimental in terms of neonatal outcomes. The authors also conclude that second-stage caesarean sections probably do carry a greater risk to the mother than those carried out earlier; so in carefully selected women, operative vaginal delivery should still have a place in modern obstetrics.

Leung et al. (Obstet Gynecol 2009;114:1023–8) from Hong Kong studied the condition of neonates delivered by urgent caesarean section for ‘fetal distress’ as indicated by a fetal bradycardia. They then correlated the time from the onset of the bradycardia to delivery by caesarean section with the baby’s condition at birth in three groups, depending on whether the cause was judged to be irreversible (for example, placental abruption, 39 cases), potentially reversible (22 cases), or unknown (174 cases). Where the cause was irreversible, the duration of delay in delivery did make a difference to the baby’s condition at birth and as might be expected, the longer the delay, the lower the cord pH and the more adverse the outcomes. Therefore, in such cases, every effort should be made to deliver the baby as quickly as possible. However, when the cause was potentially reversible or unknown, there was no significant relationship between the bradycardia-delivery interval and pH or other measure of outcome. Therefore ‘resuscitative’ measures such as tocolysis or the correction of maternal hypotension were deemed appropriate, so avoiding the need for caesarean section if fetal recovery was observed. Bradycardia of 60 seconds or less following external cephalic version was a particular example where recovery was usually observed. The authors suggest that although a decision to start preparing for a caesarean section should be made within 3–5 minutes, it is reasonable to check for recovery of the fetal heart rate before actually commencing the procedure. It should be pointed out that throughout the study there were very rapid response times once the decision was made to carry out a caesarean section, with all deliveries achieved within 20 minutes. However, the authors commented that this was stressful for the staff, and required the use of general anaesthesia, increasing the risk to the mother. For these reasons, a more measured approach is probably reasonable in cases without an obvious irreversible cause. The team also emphasise that bradycardia-to-delivery intervals yield more important data than decision-to-delivery times, especially when interpreting suboptimal outcomes.

Robotic surgery for novices

  1. Top of page
  2. Menopausal transition and incontinence
  3. Zoledronic acid and bone loss
  4. Operative delivery
  5. Robotic surgery for novices

Robotic surgery in gynaecology is evolving and being increasingly reported—not as randomised trial outcomes as yet—and as such needs to be understood by the rank-and-file of the discipline.

The best-known application is the da Vinci Surgical System introduced 10 years ago and approved for gynaecological operations in the USA by the Food and Drug Administration in 2005. It has four components:

  • 1
    A console in theatre but remote from the woman in which the surgeon sits, unscrubbed, and controls the operation by finger graspers which move the instruments electronically in the abdominal cavity. The action is shown on a screen which is adjustable using foot pedals
  • 2
    A cart adjacent to the woman with robotic arms. Three or four of these arms hold the interactive operating instruments through trocars
  • 3
    An endoscopic camera which is inserted in the midline. It is 12 mm in diameter and provides a three-dimensional picture
  • 4
    Multi-jointed instruments that are computer assisted to translate the surgeon’s console movements to intra-abdominal action. Typically, the size of the movements is reduced ten-fold, which greatly increases the delicacy and precision of the surgery.

The surgical team inserts the gas, endoscope and trocars and connects them for robotic control. They will also replace the initial instruments with sutures, suction or any other tool the primary surgeon needs. The surgeon has command of the view, the instruments and tissue manipulation.

The advantages are that the three-dimensional camera gives good depth perception, the multiple jointing of the instruments allows access to remote areas, the movement reduction reduces tremor and the resulting improved dexterity facilitates complex procedures. Finally, telesurgery becomes a real possibility.

The disadvantages are the cost, being over US$1 million for the system and the disposable instrumentation is also expensive. It takes quite a long time to set up the operation. At present poor tactile feedback makes it difficult to judge resistance, although this will improve with the development of haptic technology with sensors on the instruments, which feed back force, vibration and motion. It is also very difficult to reposition the patient once the system is set up, and finally the robotic deck is bulky, making the assisting team’s job difficult.

No doubt dual consoles will be developed for training plus education as the technology improves and costs come down. Although trials are lacking it is being adopted in selected units and presumably it will gain credentials with time (ACOG Technology Assessment #6 Obstet Gynecol 2009;114:1153–5).