Search

Teneinde het aantal herzieningen van primaire WAO-beslissingen te verminderen is inzicht in de factoren die leiden tot een herziening na bezwaarprocedure van belang. Vraagstelling: Welke factoren zouden een herziening van de primaire beslissing in bezwaar kunnen voorspellen?Methode: De WAO-bezwaarzaken van UWV Rotterdam uit 2002 waarbij medisch inhoudelijke zaken een rol speelden, werden retrospectief onderzocht. Er waren 361 dossiers beschikbaar voor analyse. Met univariate analyse werd het effect van client- en verzekeringsartsgebonden factoren alsmede proces- (organisatorische) factoren op de uitkomst van de bezwaarbeslissing onderzocht. Deze factoren werden vervolgens onderworpen aan multivariate analyse om voorspellers (predictoren) van een herziening in bezwaar te bepalen.Resultaten: Het wel opvragen van medische informatie door de bezwaarverzekeringsarts (BVA), het niet hebben van klachten van het bewegingsapparaat en hogere leeftijd van de client waren bij univariate analyse gerelateerd aan een grotere kans op wijziging van de primaire beslissing door de BVA.In de multivariate analyse hadden deze factoren een matig voorspellende invloed op een wijziging door de BVA en een gegrondverklaring bij de juridische beslissing. Bij de laatste hadden tevens een lange (>6 maanden) interval tussen het indienen van een bezwaar en het oordeel van de BVA alsmede de aanwezigheid van een begeleider tijdens het spreekuur van de BVA, een matig voorspellende waarde.Conclusie: Het opvragen van medische informatie door de bezwaarverzekeringsarts (BVA), de afwezigheid van klachten van het bewegingsapparaat en een hogere leeftijd van de client kunnen een wijziging door de BVA en een gegrondverklaring bij de juridische beslissing matig voorspellen. Voor de juridische beslissing zijn ook een lang interval (>6 maanden) tussen indienen bezwaar en oordeel BVA en de aanwezigheid van een begeleider op het spreekuur van de BVA van belang.

Ons doel was evaluatie van de frequentie en de manier van overleg tussen bedrijfs-/verzekeringsartsen enerzijds en fysiotherapeuten anderzijds. Tevens werd in beide groepen de persoonlijke ervaring van genoemde aspecten geevalueerd. In het totaal zonden 64 bedrijfs-/verzekeringsartsen en 407 fysiotherapeuten in de regio Rijnmond een vragenlijst betreffende bovenstaande aspecten ingevuld terug. De vragenlijst werd gevalideerd, gebruikmakend van constructvaliditeit en contentvaliditeit. Bovendien werd de test interne consistentie verricht om de betrouwbaarheid van de vragenlijst te verzekeren. Beide groepen stellen onderling overleg op prijs. Fysiotherapeuten hebben echter behoefte aan meer overleg. Het initiatief om de andere groep te benaderen ligt veelal bij de artsen. De bijdrage van de therapeuten aan reintegratie in arbeid van hun clienten wordt door de therapeuten hoger geschat dan door de artsen. De frequentie van overleg tussen bedrijfs-/verzekeringsartsen enerzijds en fysiotherapeuten anderzijds is vrij gering. De kwaliteit daarvan wordt door de meerderheid van beide groepen als vrij goed aangegeven. In tegenstelling tot de fysiotherapeuten zijn de artsen van mening dat de fysiotherapeutische interventie geen positieve invloed heeft op hervatting van werk en dat er voldoende overleg plaatsvindt.

The aim of the study was to investigate the occurrence and duration of micromotions of the bladder wall. Thirty women with CPP and 7 healthy women underwent micromotion detection (MMD). A latex balloon provided with eight electrodes was placed within the bladder through the urethra and filled with saline up to 200 ml. Micromotions (MM), pressure within the balloon, abdominal pressure and respiratory excursions of the abdomen were registered simultaneously. A significant difference in duration as well as frequency of occurrence was found for MM activity between subjects with CPP and controls. For the occurrence of variations in detrusor presure, the difference between groups tended towards significance. We conclude that there are indications that the bladder is involved in CPP.

Objecti6es: To assess the mean duration of use of HRT in general practice and to identify determinants of the duration of HRT use. Methods: A general population of 1689 women aged 45‐60 years and enlisted in five group practices of general practitioners were followed for 9 months to trace first HRT prescriptions. All 103 women who were prescribed HRT were followed for a period of 2.25 years. Duration of HRT was assessed by using the data provided on the dispensing of HRT. Possible determinants of duration of use, such as attitude towards menopause, menopausal status and another six variables were measured by means of a questionnaire. Results: None of the 103 women received HRT for a preventive purpose; the main indication was menopausal complaints. More than 60% of the women stopped their HRT within 6 months and only 8% of the women remained on HRT for more than 2 years. The mean duration of use was 7 months. Determinants that significantly predicted the duration of HRT use were age, attitude towards treatment of the menopause and the group practice. Conclusions: The mean duration of HRT use is very short, despite the fact that the most prevalent indication is the alleviation of menopausal symptoms. Apparently, Dutch women are presently unwilling to take HRT for longer periods. © 1998 Elsevier Science Ireland Ltd. All rights reserved.

PURPOSE: It has been suggested that hysterectomy has a disturbing influence on bowel function. To assess the incidence and nature of these changes, we performed a retrospective study. METHODS: A retrospective study was performed in all 593 women who had undergone hysterectomy between 1989 and 1993. A control group consisted of 100 women who had undergone laparoscopic cholecystectomy. RESULTS: The response rate was 90 percent (n=531; median age, 45 (range, 18–84) years). Of the responding women, 315 patients (59 percent) indicated a normal defecation pattern before hysterectomy. Of these women, severe deterioration in bowel function was reported by 98 patients (31 percent), whereas 36 women (11 percent) mentioned a moderate change after hysterectomy. Most frequent symptoms were severe straining (90 patients), incomplete and/or digital evacuation (83 and 50 patients, respectively). According to most patients, the changes in bowel function were reported to have started within one month after hysterectomy. With advancing age, fewer complaints were recorded (P=0.008). No significant difference was found in the incidence of disturbed bowel function between the different types of operation (abdominal, vaginal, supravaginal, or radical hysterectomy). In the control group, the response rate was 96 percent. Median age of these women was 46 (range, 25–78) years. Fifty-eight patients (60 percent) reported normal bowel function before laparoscopic cholecystectomy. In this group of patients, disturbed bowel function after surgery was reported by five women (9 percent), which figure is significantly (P< 0.001) lower compared with that in the corresponding hysterectomy group. CONCLUSION: Hysterectomy seems to play an important role in the pathogenesis of disturbed defecation.

OBJECTIVE: The authors determined the prevalence of incisional hernia and nerve entrapment in patients with a low transverse Pfannenstiel incision. SUMMARY BACKGROUND DATA: The literature on the Pfannenstiel incision suggests an incisional hernia rate of 0.0% to 0.5%. However, in these series, physical examination, which is essential in the authors' view, was not performed. To the authors' knowledge, the prevalence of nerve entrapment after the Pfannenstiel incision is not known or has never been published. METHODS: All adult women, operated on between 1986 and 1992 using a Pfannenstiel incision and not having had another lower abdominal incision other than for laparoscopy, were invited for follow-up at the outpatient department. All patients were interviewed and subjected to a physical examination, with special interest to the presence of incisional hernia or nerve entrapment. RESULTS: In patients having had a Pfannenstiel incision, no incisional hernias were found. In patients also having had a laparoscopy, the incisional hernia rate was 3.5%. Nerve entrapment was found in 3.7%. The length of the incision was identified as a risk factor (p = 0.02). CONCLUSIONS: Incisional hernia is a rare complication of the Pfannenstiel incision. Complications of nerve damage, however, are not uncommon and should be recognized. When possible, nerves should be identified and preserved, especially when extending the incision more laterally.

To determine more closely the relationship between vasomotor symptoms, well-being and climacteric status according to the last menstrual bleeding and according to the women themselves. Methods: A population-based cross-sectional study was executed using a postal questionnaire. Well-being of women with and without vasomotor symptoms was compared, for the different menopausal statuses. All 2729 women living in a commuter suburb of Rotterdam aged 45–60 years were approached of whom 1947 (71.3%) responded. Well-being was measured by the Inventory of Subjective Health (ISH) and three subscales of the Sickness Impact Profile (SIP). Results: The results showed that the relationship between vasomotor symptoms and well-being was dependent on climacteric status. Pre-and (middle and late) postmenopausal women with vasomotor symptoms more often experienced a relatively lower level of well-being compared to women without these symptoms. However, when the prevalence of vasomotor symptoms is as its peak, i.e. in late perimenopause, a difference in the level of well-being between women with and without vasomotor symptoms was absent. Conclusions: It is concluded that well-being and vasomotor symptoms were inversely related in all menopausal statuses except for the (late) perimenopausal phase. For this no somatic explanation seems plausible. A more social scientific explanation is suggested.

To evaluate short-term results and long-term patients' satisfaction of abdominal colposacropexy performed for massive genital prolapse in our institute during a 14-year period. A restrospective analysis was performed of 101 consecutive women who underwent abdominal colposacropexy. The procedure consisted of retroperitoneal interposition of a Mersilene mesh between a prolapsed vaginal vault or uterus and the anterior surface of the sacrum. A questionnaire was used to evaluate patients' satisfaction after surgery. In the short-term there was an acceptable rate of complications of surgery, comparable with that reported in the literature. Prolapse-related complaints evaluated by questionnaire were markedly diminished after surgery. Pain and functional complaints were only partly improved in a subgroup of patients. Only 32% of the patients responded that they were fully cured after operation. Abdominal colposacropexy shows a particularly favorable result on prolapse-related complaints. Functional complaints and pain are not substantially relieved by this procedure. The complication rate of surgery is acceptable.

The aim of the present study was to ascertain the cumulative incidence of first hormone replacement therapy (HRT) and the factors that predict its prescription. In a general population 1689 women were followed for 9 months in order to trace first HRT prescriptions. Determinants (well-being, attitude towards menopause, menopausal status and another 9 variables) were measured by means of a questionnaire. Data analyses were performed for all women and for women with or without typical climacteric complaints. The cumulative 9 month incidence of HRT was 6.2%. For women without typical complaints a lower level of well-being (odds ratio 5.5; 95% CI 1.9-15.5) and the former use of the contraceptive pill (odds ratio 4.6%; 95% CI 1.0-20.5) were independently associated with HRT prescription. For women with typical complaints a positive attitude towards 'menopause should be treated' (odds ratio 3.8; 95% CI 1.8-8.0) was a determinant of HRT prescription. The cumulative incidence of HRT prescription is high, but from additional data it is apparent that within a period of 1 year and 9 months the majority of women stop taking HRT. For women without typical complaints, physicians prescribe HRT five times more often to those with a lower level of well-being. For women with typical complaints the physician's prescription is primarily related to the woman's attitude towards (medical) treatment of the menopause.

OBJECTIVES: Is there an influence of oral contraceptive use, parity and lactation on early postmenopausal bone mass? Is assessment of reproductive history, body weight in combination with biochemical markers of bone metabolism suitable to predict lumbar bone mass soon after menopause?STUDY DESIGN: A cross-sectional study in 94 healthy, normal weight, non-smoking women, 1-3 years after spontaneous menopause. Bone mineral density (BMD) of the lumbar spine was measured with single energy quantitative computed tomography.RESULTS: Multiple regression analysis showed that only total duration of lactation and alkaline phosphatase (AP) levels are independently related to trabecular BMD (P = 0.001 and P = 0.002 respectively). AP was also associated with cortical BMD (P = 0.003). Assessment of reproductive history, body mass index and biochemical markers of bone metabolism could only account for 17% of the variation of trabecular BMD observed in the study population.CONCLUSION: This study suggests that total duration of lactation rather than parity is associated with trabecular BMD of the spine. Clinical assessment of risk factors unsuccessfully predicts lumbar BMD in healthy, early postmenopausal women.

A case of a primarily extra-uterine low-grade endometrial stromal sarcoma is described. The patients clinical course, including various surgical, chemotherapeutical and hormonal therapies, is outlined and discussed. Transition from benign endometriosis to clinically malignant endometrial stromal sarcoma is illustrated by microscopy and DNA flow cytometry. A change in nuclear DNA content is demonstrated. This is possibly a useful aid in identifying the malignant potential of this tumor with such a misleading microscopic appearance.

Although melatonin (MEL) controls seasonal reproductive cyclicity in some mammalian species, its role in women is controversial. In this study data are presented related to the influence of MEL or MEL-progestin combinations on the pituitary-ovarian axis and ovulation in 32 women. MEL was administered in a dosage of 300 mg to 12 women for 4 months [to 8 women daily (days 1-30) and to 4 women on days 5-17 of the cycle]. MEL was also combined with the synthetic progestin norethisterone (NET) in an attempt to evaluate MEL's effect on a partially suppressed pituitary-ovarian axis. In 16 women, 4 combinations were tested on 4 women each on days 1-21: dosages of 300 mg MEL/0.75 mg NET, 75 mg MEL/0.75 mg NET, 7.5 mg MEL/0.75 mg NET, and 75 mg MEL/0.30 mg NET. In addition, 2 women were medicated with 300 mg MEL alone, and 2 were medicated with 300 mg MEL/0.15 mg NET on days 1-21 for 2 months. During the study, LH, FSH, estradiol (E2), and progesterone (P4) blood levels were determined at regular intervals. After a period of 4 months, daily administration of 300 mg MEL (days 1-30) caused significantly decreased mean LH levels compared to those in 8 nonmedicated controls (P less than 0.001). Also compared to nonmedicated control data, a significant inhibition of P4 in the first and fourth medication months (P less than 0.001) was observed. LH and E2 inhibition reached significance in the fourth medication month (P less than 0.005). Also, the treatments of 300 mg MEL (days 5-17) and 75 mg MEL combined with 0.3 mg NET caused a significant decrease in LH, E2, and P4 levels compared to those in the nonmedicated control group in the first and fourth medication months (P less than 0.05). The data further suggest an additive or synergistic effect between MEL and NET. The medications did not alter sleep-wake rhythms and were not complicated by any side-effects. The presented data suggest that MEL and MEL/NET combinations inhibit ovarian function in women, and that MEL/NET combinations can emerge as effective oral contraceptives.

Eighty-one women with chronic pelvic pain caused by a gynaecological abnormality (group 1) were compared with 81 women with chronic pelvic pain without an organic cause (group II). A control group of 46 pain-free women was included (group III).The purpose of this study was to investigate the hypothesis that patients with unknown pelvic pain would have more neurotic problems than patients with an organic cause for their pain. All patients were tested on the Minnesota Multiple Personality Inventory (MMPI). Women from group I and group II did not differ significantly on the neurotic triad of the MMPI. There was, however, a significant difference between group I and group III and between group II and group III on the MMPI scores.From the results it can be concluded that chronic pelvic pain can lead to neurotic behavior and that scores on the MMPI cannot differentiate between patients with or without organic chronic pelvic pain.

Item does not contain fulltext OBJECTIVE: To establish the prevalence of voiding symptoms in CPP patients. STUDY DESIGN: Sixty women with chronic pelvic pain (CPP), aged 23-79 (mean: 48) years completed a questionnaire mainly addressing lower abdominal pain and voiding symptoms. Symptoms occurring often, almost always, or always for more than 6 months were considered present and serious. A group of 31 consecutive cases of non-CPP women aged 18-77 (mean: 49) years were selected to serve as controls. RESULTS: The following symptoms were found in the CPP group: incontinence: 43%; inadequate voluntary control of the urethral sphincter: 50%; inability to postpone: 37%; urge: 37%; nocturia > or =2X: 18%; dysuria: 12%; cystitis: 37%; urge-induced pain: 20%; pain-induced urge: 18%; strain to initiate voiding: 6%; strain to continue voiding: 17%; incomplete voiding: 37%. Two or more voiding symptoms were present in 63% of the CPP group. All urinary symptoms were more often present in the CPP group than in the controls. CONCLUSION: A substantial subgroup of CPP patients has voiding symptoms.

A technique has been developed to detect local movements in bladder wall. These micromotions (MMs) are assumed to play an important role in the origin of urge sensations. The MMD-16 interface in combination with a special designed MMD probe is able to detect MMs at 8 or 16 locations. A pilot study with 11 patients demonstrated the relevance of recording the MMs in addition to routine urodynamic examination.

A MicroMotion Detection technique has been developed to detect small local motions in the walls of hollow organs, particularly the bladder. The four-points impedance measurement method has been applied for detecting small distance variations between electrodes mounted at the inner surface of a latex balloon filled with saline. Measurements in the bladder of patients have shown the clinical feasibility and relevance of this technique. This paper deals with the "crosstalk" problem, caused by the movement of current electrodes and giving an unwanted contribution to the potential difference between the voltage electrodes. A mathematical model is presented that is used to calculate the distance variations from the voltage variations despite the influence of crosstalk. Moreover, the relations between measured voltages and the interelectrode distances can be used to optimize the electrode configuration to reduce the crosstalk factor beforehand. The relations presented in this paper are verified with measurements and with simulations using a Boundary Element Model. The relations can be useful to interpret signals recorded with the four-points impedance measurement technique and to design probes for other applications.

Objectives: No standard screening instrument is available enabling physicians to assign the diagnosis chronic pelvic pain (CPP) to women with lower abdominal pain. Therefore, our aim was to evaluate an easy-to-use questionnaire, which can be applied as a validated primary screening test for diagnosing CPP. Study design: From the general female population, 577 women completed a questionnaire addressing chronic symptoms in the pelvic region. Included were (amongst others) questions on lower abdominal pain, low back pain, voiding symptoms, dyspareunia, pelveo-perineal dysesthetic feelings and evacuation problems. Serious chronic lower abdominal pain of unknown origin was considered as CPP. Three criteria were applied to validate the questionnaire: construct validity, comparison with results of a previous study and content validity. In addition, the internal consistency was checked to ascertain the reliability of the questionnaire. Results: All items, with the exception of those concerning voiding symptoms and dyspareunia, withstood the validity tests applied, were interrelated and occurred significantly more often in women with CPP than those without. There were no significant differences in the frequency of the occurrence of low back pain, dyspareunia and evacuation problems between CPP women in the current community study and outpatients diagnosed with CPP in an earlier study performed at the University Hospital Rotterdam. Compared to our current study group, pelveo-perineal dysesthesia (PPD) and voiding symptoms were significantly more often reported by the CPP outpatients. Conclusion: The CPP questionnaire can be considered as a validated tool for primary screening of CPP.

Vulvar vestibulitis, a subset of vulvodynia, is present in 15% of patients in a general gynecologic practice. Only a few studies have focused on pathologic features of vulvar vestibulitis and none have included a control group. Punch biopsies from the vulvar vestibule of 12 patients with an age range of 22 to 51 years (mean 28 years) and 12 age-matched controls were analyzed for histopathologic features and investigated for the role of probable etiologic factors including human papillomavirus (HPV). A chronic inflammatory infiltrate was present in all specimens from patients with vestibulitis, and was composed predominantly of T-lymphocytes with a small number of B cells and an admixture of plasma cells, mast cells, and occasional monocytes. T-helper suppressor ratio was normal. The infiltrate was mild in 5 patients, moderate in 1, and severe in 6. Minor vestibular glands were observed in 8 (66%) patients and were associated with a periglandular inflammatory infiltrate. Squamous metaplasia was observed in 4 (44%) patients. Epithelial hyperplasia was present in 10 (83%) patients with mild dysplasia in 2 (16%). Immunohistochemistry for immunoglobulins IgG, IgA, and IgM showed the presence of IgG-positive plasma cells in 75% of patients, suggesting chronic irritation, but an autoimmune etiology cannot be excluded or confirmed. Biopsies of control cases did not show any inflammatory infiltrate. In situ hybridization for HPV 6, 11, 16, and 18 was negative in the patient group as well as in the control group. We conclude that histopathologic abnormalities in patients with vulvar vestibulitis are the result of a chronic inflammatory reaction of the mucosa of the vulvar vestibule, for which the cause remains unclear.

This article describes the outcome of a behavioral approach with or without preceding surgical intervention in 48 women with the vulvar vestibulitis syndrome. In the first part of the study, 14 women with the vulvar vestibulitis syndrome were randomly assigned to one of two treatment programs: either a behavioral approach or a behavioral approach preceded by surgery. In the second part of the study, 34 women and their partners were given a choice of treatment. Follow-up data were gathered a mean of 3 and 2 1/2 years after treatment, respectively. In the randomized patient population, the intervention had a positive effect on all of them: the complaints disappeared, diminished or did not change but formed less of a problem. The difference in outcome between the two different treatments, a behavioral approach with or without preceding surgery, was not statistically significant. In the second non-randomized part of the study, 28 out of the 34 women (82%) chose the behavioral approach without preceding surgery. The difference in outcome between the two treatments was not statistically significant. Two out of the 28 women who chose behavioral treatment without preceding surgery had to be referred for psychiatric consultation because of serious psycho-sexual problems. In one woman, psychiatric treatment was successful. Three other women, whose behavioral treatment failed, underwent additional surgery, which clearly helped them to overcome the deadlock in the behavioral approach. The behavioral approach should be the first choice of treatment for the vulvar vestibulitis syndrome. Surgical intervention should be considered as an additional form of treatment in some cases with the vulvar vestibulitis syndrome to facilitate breaking the vicious circle of irritation, pelvic floor muscle hypertonia and sexual maladaptive behavior.

To compare the analgetic efficacy and side-effects of Naproxen and Tramadol following the outpatient VABRA aspiration or hysterosalpingography.Ninety-one patients from the gynaecology clinics of two university hospitals and one municipal-teaching hospital.Multicentre double blind randomized clinical trial. Computerised randomisation, stratification per-centre.Semiquantitative assessment of the two drugs was performed by the patient and the gynaecologist using a 1- to 6-point scale. Pain, stress and well-being was scored by the patient using the visual analog scale (VAS) and the verbal description scale (VDS), ranging from 0 (good) to 100 (bad). Side-effects during the first 24 h postoperatively were recorded by the patient in a diary.The analgetic efficacy (pain, stress and well-being) of Naproxen and Tramadol was identical. Subjective assessment by the patient and the doctor also revealed no differences between Naproxen and Tramadol. Side-effects of Tramadol, however, were significantly more severe than those of Naproxen and this phenomenon was responsible for a lower ability to proceed with normal activities in the Tramadol group.Tramadol is a good alternative for Naproxen at outpatient VABRA or HSG procedures when Naproxen is contra-indicated.

Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia or male transsexualism, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest.One patient with Mayer-Rokitansky-Küster syndrome developed a protrusion of the sigmoid neovagina almost 4 years after the initial operation. The prolapse was treated successfully using an abdominal approach to suspend the neovagina to a Cooper ligament. The second patient is a male-to-female transsexual who developed a prolapse 3 years after the creation of a sigmoid neovagina. After suspension of the neovagina to a Cooper ligament, the prolapse recurred; in a repeat approach, the neovagina was successfully suspended to the sacral promontory. The third patient, with Mayer-Rokitansky-Küster syndrome, complained of a protrusion immediately after creation of the neovagina. Initially, the redundant sigmoid was resected vaginally. However, the prolapse recurred, and an abdominal suspension to a Cooper ligament was performed. Finally, after 1 year, another recurrence was treated successfully with a vaginal approach.Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Both abdominal and vaginal approaches may be needed to restore the neovagina without compromising its function.

The bacterial microbiota of 15 sigmoid neovaginas, created in patients with congenital vaginal aplasia or male transsexualism, was studied. No specimen was sterile, and only normal inhabitants of the colon were cultured. The total counts of bacteria were lower than those reported for healthy sigmoid colons.

Objective: We aimed to study the long-term psychosexual and psychosocial performance of patients with a sigmoid vagina in vaginal dysgenesis and male-to-female transsexuals. Study Design: Nineteen patients who had undergone surgery to create a neovagina with the use of a sigmoid segment participated in a long-term follow-up study. Evaluation was done with standardized gynecologic examination and a structured interview. Results: The anatomic result was good in 18 patients, although several reoperative procedures had been necessary. Sexual adjustment was good or satisfactory in 12 of 19 patients. Of the 19 patients, 16 were capable of reaching an orgasm. Social adjustment was good or satisfactory in 16 patients. Conclusions: The creation of a sigmoid neovagina results in a long-term anatomically satisfactory situation, in both patients with vaginal dysgenesis and male-to-female transsexuals. In a majority of the patients sexual and social adjustment is good or satisfactory.

The objective of the study was to assess the opinion of women about the use of hormone replacement therapy (HRT) in relation to continuation or re-induction of bleeding periods after menopause. The design was a population-based cross-sectional study using a postnatal questionnaire in Krimpen aan den IJssel, a commuter suburb of Rotterdam. The participants were all 2729 women living in Krimpen aan den IJssel aged 45-60 years, of whom 1947 (71.3%) responded. The main outcome measure was an opinion on monthly or trimonthly withdrawal bleedings with HRT. The results showed 16.9% of all women have no or little objection to use of HRT with monthly withdrawal bleedings. There is a marked difference between premenopausal women (32.4% have no or little objection) and postmenopausal women (only 9.2% have no or little objection). Trimonthly cycles during HRT tend to be perceived as more acceptable (41.4% of premenopausal women and 11.8% of postmenopausal women have no or little objection). It is concluded that a reasonable proportion of premenopausal women accept continuation of periodic bleeding with HRT. There is a preference for trimonthly cycles rather than monthly withdrawal bleedings. Most postmenopausal women object to having withdrawal bleedings with HRT, irrespective of a monthly or trimonthly cycle. Research should continue on schedules without withdrawal bleedings.

Diversion colitis is an inflammatory process occurring in segments of the colorectum surgically diverted from the fecal stream. Clinical symptoms of this condition are rectal discomfort, pain, discharge, and bleeding. We diverted isolated segments of sigmoid to create neovaginas in patients with aplasia vaginae and in male to female transsexuals. In contrast to what is reported in most studies of diversion colitis, the neovagina consists of an isolated segment not connected to the anus in patients without any pre-existing bowel disease. To investigate the occurrence of diversion colitis in these sigmoid-neovaginas we studied biopsy specimens from 13 patients. Most of the patients complained of discharge and slight blood loss from their sigmoid-neovagina. Microscopic examination of the biopsy specimens showed lymphocytic infiltration in all cases. Four cases showed an acute inflammatory infiltrate in the lamina propria. Our results indicate that the changes observed on clinical and histopathologic examinations represent the entity of mild diversion colitis. We conclude that diversion colitis also occurs in a sigmoid neovagina.

The climacteric is accompanied by many changes in life, which may give cause to a variety of complaints. Thus, it may be difficult to discern to what extent the climacteric is related to well-being. The association between menopausal status and well-being was determined in a population of 2729 women aged 45-60 years. A self-administered questionnaire was filled out and returned by 1947 women (response 71.3%). Well-being was measured by the Inventory of Subjective Health (ISH) and the three subscales of the Sickness Impact Profile (SIP): social functioning; emotions, feelings and sensations; and intellectual functioning. The relationship between menopausal status and well-being was estimated using linear regression analysis, while adjusting for age and other potential confounding variables, including body mass index, smoking behavior, education, work outside the home, parity, way of cohabitation, difference in age with the partner and partner's employment. The results show that early perimenopausal women report a lower level of well-being as compared to premenopausal women on all three SIP scales. Early postmenopausal women report a lower level of well-being on the SIP emotions, feelings and sensations. Intermediate postmenopausal women have a lower level of well-being on the ISH only. Finally, late postmenopausal women have a lower level of well-being on the SIP social functioning and SIP emotions, feelings and sensations. We tentatively conclude that the influence of the climacteric on well-being independent of confounders is primarily found in behavioral functioning in the daily life of a woman.

The creation of a functional vagina in patients with congenital vaginal aplasia or male transsexualism is a challenging problem. A group of 40 patients, including 23 male transsexuals, in whom a neovagina was created using a sigmoid transplant, is reported. The technique, a modification of Kun's "colocolpopoiesis," is described in detail. Ten patients showed some direct postoperative complications and five were readmitted the first six weeks postoperatively for a variety of reasons. No extensive complication occurred. Thirty-two patients were evaluated at the routine six week postoperative check-up. Four patients had had intercourse at that time and an adequate vagina was found in 21 other patients. It is concluded that this modification of Kun's technique, known as colocolponeopoiesis, has had, at short term in the majority of patients, functionally good results and an acceptable complication rate.

Heat-inactivated human serum is added to the culture medium used for in vitro fertilization and other forms of assisted conception. Because one batch of pooled serum contained hepatitis B virus, an epidemic occurred among women participating in the treatment program. Seventy-nine women had serologic proof of hepatitis B infection. This incident gave the opportunity to study the effect of hepatitis B virus on pregnancy outcome and the newborn. The situation is unique because the preimplantation embryo was exposed to hepatitis B virus or the pregnancy was complicated by a (sub)clinical infection. Twenty-four women were or became pregnant while having an acute hepatitis B infection. Five pregnancies ended in abortion. The remaining 19 pregnancies ended in the birth of 24 children. No evidence for any harmful effect of exposure to hepatitis B virus in the embryonic or fetal period on the newborn could be found.

A method is described for determination of the stress-relaxation characteristics of the cervix uteri of non-gravid women after almost stepwise dilatation of the cervical canal by a water-filled balloon. The stress relaxation is followed by measurement of the pressure decay in the same balloon. Application of this atraumatic technique to women with a normal cervix and women known to have an incompetent cervix yields diagnostic ranges of various parameters, in particular a time constant and the elastic ratio. The technique seems promising for easy detection of cervical incompetence, allowing suitable measures to be taken for prevention of immature deliveries. A mechanical model of the tissue of the ostium internum has further been developed on the basis of the measured characteristics.

Summary In 15 women, peritoneal fluid was obtained by either culdocentesis (n= 20) or laparoscopy (n= 3), before (n= 9) and after (n= 14) ovulation. Ultrasound was used for ovulation detection. Before ovulation the mean oestradiol-17β level in plasma and peritoneal fluid was not essentially different; the mean progesterone level was significantly higher in peritoneal fluid. After ovulation both the mean oestradiol-17β and progesterone levels were significantly higher in peritoneal fluid than in plasma. In peritoneal fluid, there was a wide distribution of individual oestradiol-17β values before and after ovulation; no significant difference existed between the mean pre- and postovulatory oestradiol-17[3 level. More consistent changes were seen in peritoneal fluid progesterone levels; the mean level was significantly higher after ovulation. In three subjects, a low postovulatory progesterone level in peritoneal fluid was associated with a cystic luteal structure observed by ultrasound, suggesting a reduced leakage of fluid from the ovulation stigma. Erasmus University, Rotterdam Department of Obstetrics and Gynaecology R. F. P. M. KRUITWAGEN

This prospective, randomized, 'blind' study with guinea-pigs was performed to assess the possible benefit of 6% dextran 70 (molecular weight 70 000) in the prevention of post-operative intra-abdominal adhesions and recurrent adhesions after adhesiolysis. In 50 guinea-pigs lesions for inducing adhesions were applied at the end of the uterine horn. On the right side a strip lesion was made and on the left side an end-to-end anastomosis was performed after section. Before closing the peritoneum 20 ml 6% dextran 70 (N = 25) or saline (N = 25) were introduced into the peritoneal cavity. A second laparotomy 4 weeks later showed no differences in adhesion formation in the animals treated with 6% dextran 70 and saline. In the animals with adhesions adhesiolysis was performed and 6% dextran 70 or saline was left in the peritoneal cavity. Again no beneficial effect of dextran was seen. The end-to-end procedure appeared to be far more suitable for producing adhesions than was the strip lesion.

Eighty-one women with chronic pelvic pain caused by a gynaecological abnormality (group 1) were compared with 81 women with chronic pelvic pain without a demonstrable gynaecological disease (group II). A control group of 46 pain-free women was included (group III). All patients were tested on the Sexual Experience Scale (SES). Women from group I and group II did not differ significantly on the four subscales of the SES. There was, however, a significant difference when groups I and II were compared with group III, regarding the SES scores. From these results it can be concluded that patients with chronic pelvic pain have more sexual problems compared with pain-free patients. A model for practical work in the outpatient clinic has been constructed and introduced.

The energy levels of the nucleus of a K+ ion near a paramagnetic Gd3+ ion, both substituted in CaF2, have been measured with the recently developed technique of electron spin echo envelope modulation, combined with an also recently developed microwave cavity, the loop-gap resonator. The results provide confirmation of the theory of lattice distortion around substituted ions.

In 28 females, daily measurement of the HCG concentration in urine and in 15 of them daily measurement of the beta-HCG concentration in plasma was carried out during the first 2 weeks following first-trimester induced abortion by vacuum aspiration. Plasma beta-HCG concentration fell according to a multi-exponential curve with a half-life of 0.63 days in the first 2 days following induced abortion, and of 3.85 days in the subsequent 14 days. The disappearance of HCG from urine is exponential, with a half-life value of 1.3 days. A urine pregnancy test with a sensitivity of 1 IU/ml wil nearly always be negative in the course of 2 weeks after abortion. A positive test 4 weeks after abortion indicates an incomplete abortion or persistent trophoblast.

In this paper the first known case is presented in which an antepartum diagnosis of placenta membranacea was made by ultrasound. A multiparous woman is presented with intermittent painless vaginal bleeding in the second trimester of pregnancy. Ultrasonic examination at 20 weeks' gestation revealed a gestational sac almost completely covered with placental tissue. At 26 weeks the patient delivered a dead, growth retarded and an almost complete placenta membranacea.

(1979). Colposcopy in a Case of Suspected Genital Herpes Infection in Early Pregnancy. Acta Obstetricia et Gynecologica Scandinavica: Vol. 58, No. 2, pp. 221-223.

Cervical specimens were collected from 1688 women attending a gynaecological clinic for induced abortion between February and December 1978. Thirteen (0.77%) women had positive culture results for Neisseria gonorrhoeae. Among those women who had a completed family or who came from outside Rotterdam or from outside the neighboring Rijnmond area, the isolation rate was very low. None of the women with positive culture results developed salpingitis after abortion; all of them had been treated prophylactically with tetracycline. No reasons appear to exist for considering women who seek abortions to be in a high-risk group for cervical gonorrhoea. Whether or not antibiotic prophylaxis should be given for the prevention of salpingitis following abortion requires further study of potentially pathogenic micro-organisms inhabiting the vagina and cervix for women applying for abortion.Abortion performed in women with cervical gonorrhea may result in increasing infection. For this reason cervical specimens were collected from 1688 women attending a gynecological clinic for induced abortion in an urban center in the Netherlands between February and December 1978. 13 of the women, 0.77%, had positive culture results for Neisseria gonorrhea. Among those women who had a completed family or who came from outside Rotterdam or from outside the neighboring Rijnmond area, the isolation rate was very low. None of the women with positive culture results developed salpingitis following abortion. All of the women were treated prophylactically with tetracycline. There appear to be no reasons for considering women who seek abortions to be in a high-risk group for cervical gonorrhea.

A double-blind controlled clinical trial of the new, not yet commercially available drug, carnidazole and tinidazole, was carried out in 77 women with a proven vaginal trichomoniasis. 39 patients and their sexual partners received a single dose of 2 g of carnidazole and the other 38 couples were treated in the same manner with tinidazole. The cure rate was 100% and 95% respectively. The side-effects were higher in the carnidazole group, although they were mild and well-tolerated by the patients and their partners. The history of the disease and its treatment are also briefly reviewed.

Quantitative Röntgen microdensitometry (QMD) can be used to provide a precise quantification of mean specific bone mass (rho) from standardized radiographs. The method is simple, non-invasive, low in cost and suitable for frequent repetition. Bone mineral mass at the mid-length (largely cortical bone) of the middle phalanx of digital II of the left and right hands was investigated. Normalized quantification of bone structure can be achieved with a precision (coefficient of variation) of the order of 1%. Rho values were determined for the right and left phalanx in 273 apparently healthy women 43-73 years of age (mean menopausal age, 49.8 years) in an attempt to differentiate between normal changes with age and excessive bone mineral loss. The mean rate of age-dependent bone mineral loss was -1.4% per year in pre-menopausal women; in post-menopausal women between 50 and 57 years it was -3.5% per year and between 58 and 73 years it was -0.8% per year. The mean rate of change of bone mineral mass in the same group, as a function of the number of years after menopause, was -1.9% per year for the group 2-8 years after menopause and +0.1% per year for the group 9-20 years after menopause.

In this study we compare the efficacy of ultrasonically guided percutaneous oocyte collection for in-vitro fertilization with ultrasonically guided transvaginal oocyte collection. Forty-seven patients were prospectively randomized into two groups. Twenty-four patients underwent percutaneous follicle aspiration and 23 patients underwent a transvaginal puncture. The number of aspirated oocytes per patient showed a statistically significant difference in the two groups: 2.5 for the percutaneous puncture versus 5.2 for the transvaginal procedure. The number of embryos per patient was 2.7 in the transvaginal puncture group versus 1.6 in the percutaneous puncture group. This difference was not statistically significant. The clinical pregnancy rate per patient was 12.5% with the percutaneous approach and 30.4% with the transvaginal technique. This difference was also not statistically significant. Since the transvaginal procedure also creates less discomfort to the patient and is less time-consuming it is concluded that this approach is preferable to the percutaneous puncture technique in obtaining oocytes for in-vitro fertilization.

Cervical incompetence, that is failure of the cervix uteri to remain closed under the load of the developing embryonic sac, is one of the main causes of second-trimester abortion and premature delivery. A cervix known to be incompetent may be treated by suturing it all the way around with a synthetic fibre. However, there is a lack of a reliable technique to assess the diagnosis directly, i.e. based on the determination of the mechanical properties of the cervix. It is known that the mechanical properties change during pregnancy under the influence of hormones. Therefore one may doubt whether measurements done outside pregnancy, which clinically is preferable, is likely to be of value in predicting incompetence. Nevertheless Van Duyl et al. (1) published a retrospective study on non-pregnant women with cervices known to be incompetent and volunteers with normal cervices, that relaxation measurements yield parameters which permit a high level of discrimination between competent and incompetent. The technique is based on observation of stress relaxation after stepwise dilatation of the cervical canal by means of a cylindrical shaped nylon, i.e. almost inelastic, balloon. After insertion into the canal the balloon is inflated by filling it fastly with saline by means of an infusion pump until a reference pressure of 33 kPa is reached.