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B Risks of Hormone Therapy
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Double-blinded randomized, controlled trials have shown no overall cardiovascular benefit with estrogen-progestin replacement therapy in a group of postmenopausal women with or without established coronary disease Both in the WHI trial and the Heart and Estrogen/Progestin Replacement Study (HERS), the overall health risks (increased risk of coronary heart events, strokes, thromboembolic disease, breast cancers, gallstones) exceeded the benefits from the use of combination estrogen and progesterone Progestins counteract some but not all favorable effects of estrogen Women who have been receiving long-term estrogenprogestin hormone replacement therapy (HRT), even in the absence of complications should be encouraged to stop, especially if they do not have menopausal symptoms An ancillary study of the WHI study showed that not only did estrogen-progestin HRT not benefit cognitive function but there was a small increased risk of cognitive decline in that group compared with women in the placebo group The unopposed estrogen arm of the WHI trial demonstrated a decrease in the risk of hip fracture, a small but nonsignificant decrease in breast cancer, but an increased risk of stroke and no evidence of protection from coronary heart disease The study also showed a small increase in the combined risk of mild cognitive impairment and dementia with estrogen use compared with placebo, similar to the estrogen-progestin arm (See also discussions of estrogen and progestin replacement therapy in 26)
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C Surgical Menopause
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The abrupt hormonal decrease resulting from oophorectomy generally results in severe vasomotor symptoms and rapid onset of dyspareunia and osteoporosis unless treated Estrogen replacement is generally started immediately after surgery Conjugated estrogens 125 mg, estrone sulfate 125 mg, or estradiol 2 mg is given for 25 days of each month After age 45 50 years, this dose can be tapered to 0625 mg of conjugated estrogens or equivalent
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Blake J Menopause: evidence-based practice Best Pract Res Clin Obstet Gynaecol 2006 Dec;20(6):799 839 [PMID: 17084674]
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Ettinger B et al When is it appropriate to prescribe postmenopausal hormone therapy Menopause 2006 May Jun;13(3): 404 10 [PMID: 16735937] National Institutes of Health: National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms Ann Intern Med 2005 Jun 21;142(12 Pt 1):1003 13 [PMID: 15968015]
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Tables on FIGO (International Federation of Gynecology and Obstetrics) cervical cancer staging and functional and neoplastic ovarian tumors appear in CMDT Online at http://wwwaccessmedicinecom
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Obstetrics & Obstetric Disorders
William R Crombleholme, MD
DIAGNOSIS OF PREGNANCY
It is advantageous to diagnose pregnancy as promptly as possible when a sexually active woman misses a menstrual period or has symptoms suggestive of pregnancy In the event of a desired pregnancy, prenatal care can begin early, and potentially harmful medications and activities such as drug and alcohol use, smoking, and occupational chemical exposure can be halted In the event of an unwanted pregnancy, counseling about adoption or termination of the pregnancy can be provided at an early stage
(perception of first movement noted at about the 18th week), weight gain
B Signs (in Weeks from Last Menstrual Period)
Breast changes (enlargement, vascular engorgement, colostrum), abdominal enlargement, cyanosis of vagina and cervical portio (about the seventh week), softening of the cervix (seventh week), softening of the cervicouterine junction (eighth week), generalized enlargement and diffuse softening of the corpus (after eighth week) The uterine fundus is palpable above the pubic symphysis by 12 15 weeks from the last menstrual period (LMP) and reaches the umbilicus by 20 22 weeks Fetal heart tones can be heard by Doppler at 10 12 weeks of gestation and at 20 weeks with an ordinary fetoscope
Pregnancy Tests
All urine or blood pregnancy tests rely on the detection of human chorionic gonadotropin (hCG) produced by the placenta hCG levels increase shortly after implantation, approximately double every 48 hours, reach a peak at 50 75 days, and fall to lower levels in the second and third trimesters Laboratory and home pregnancy tests use monoclonal antibodies specific for hCG These tests are performed on serum or urine and are accurate at the time of the missed period or shortly after it Compared with intrauterine pregnancies, ectopic pregnancies may show lower levels of hCG that level off or fall in serial determinations Quantitative assays of hCG repeated at 48- to 72-hour intervals are used in the diagnosis of ectopic pregnancy as well as in cases of molar pregnancy, threatened abortion, and missed abortion Comparison of hCG levels between laboratories may be misleading in a given patient because different international standards may produce results that vary by as much as twofold
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