JPOG April 2015 HK PDF

JPOG
HONG KONG ISSN 1012-8875
JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY
Online
MAR/APR 2015 VOL. 41 NO. 2
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HAIR LOSS IN INFANCY

AND CHILDHOOD
OBSTETRICS
Cancer in Pregnancy
GYNAECOLOGY
Hysterectomy for Benign
Gynaecology Disease
CME ARTICLE
Adolescent Menstrual
Problems
YOUR PARTNER IN PAEDIATRIC AND O&G PRACTICE
JPOG MAR/APR 2015
JOURNAL WATCH
Editorial Board
Board Director, Paediatrics
Professor Pik-To Cheung
Associate Professor Department of Paediatrics and Adolescent Medicine

The University of Hong Kong
Board Director, Obstetrics and Gynaecology

Professor Pak-Chung Ho
Head, Department of Obstetrics and Gynaecology

Professor Biran Affandi

University of Indonesia
Associate Professor
Raymond Hang Wun Li
Dr Karen Kar-Loen Chan
Associate Professor Daisy Chan
Dato Dr Ravindran Jegasothy
Singapore General Hospital
Dean at the Medical Faculty,

MAHSA University, Malaysia
Dr Tan Ah Moy
Professor Kenneth Kwek
Singapore
KK Womens and Childrens Hospital,

Singapore
Dr Rajeshwar Rao
Dr Kwok-Yin Leung

Singapore
Dr Tak-Yeung Leung
Adjunct Associate Professor

Ng Kee Chong
Professor SC Ng

Singapore
Professor Hextan
Associate Professor Jeffrey Low

Chinese University of Hong Kong
National University of Singapore
Yuen-Sheung Ngan
National University Hospital, Singapore
Professor Carmencita D Padilla
University of the Philippines Manila
Professor Seng-Hock Quak

National University of Singapore
Professor Kok Hian Tan

Singapore
Dr Wing-Cheong Leung
Kwong Wah Hospital, Hong Kong SAR
Dr Catherine Lynn Silao

Dr MaryAnne Chiong
Dr Ethiraj Balaji Prasath
45
Children with mild hearing loss also
benefit from the use of hearing aids
Post-mortem serum vitamin D
valuable for assessing sudden death
in children
46
Oral immunotherapy effective at desensitising children
with peanut allergy
Dairy consumption at age 10 not related with excess
fat in late childhood
Fracture incidence can occur early after therapy for
breast or gynaecological cancer
47
Provision of free education,
contraception can reduce
unintended teen pregnancies
Thomson Fertility Centre, Singapore
Associate Professor Dwiana

Ocviayanti
University of Indonesia
48
Mental anxiety, depression mediate the association
between childhood eczema or asthma and child
mental wellbeing
Psychological interventions improve pregnancy rates
in infertile couples
JPOG MAR/APR 2015
REVIEW ARTICLE
PAEDIATRICS
Publisher Ben Yeo

Managing Editor Greg Town
Medical Editor Kavitha M
Publication Manager Marisa Lam
Designers Agnes Chieng, Sam Shum
Production Edwin Yu, Ho Wai Hung, Steven Cheung
Circulation Christine Chok
Accounting Manager Minty Kwan
Advertising Coordinator Jasmine Chay
49
Hair Loss in Infancy and Childhood
Published by:
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Hair problems in children are not uncommon

and can cause considerable anxiety among
parents and children. Conditions such as
alopecia areata and trichotillomania can
present in both adults and children but in
children one also needs to consider rarer
congenital and hereditary causes of hair loss
which can occasionally present as part of a multisystem syndrome.
Enquiries and Correspondence
Caroline Champagne, Paul Farrant
China
Yang Xuan
Tel: (86 21) 6157 3888
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Kristina Lo-Kurtz, Jacqueline Cheung, Marisa
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OBSTETRICS
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A diagnosis of cancer in pregnancy has

an incidence of 0.1%. This is expected
to rise with increasing number of women
delaying childbearing into later life.
Common malignancies are breast, cervix,
leukaemia, melanoma, thyroid, ovary
and colon. Diagnosis and treatment is a
complex balance between maternal wellbeing and fetal wellbeing.
Europe/USA
Kristina Lo-Kurtz
Tel: (852) 2116 4352
Email: kristina.lokurtz@mims.com
PUBLISHER: Journal of Paediatrics, Obstetric & Gynaecology (JPOG) is published 6 times a year by MIMS Pte Ltd. CIRCULATION: JPOG is
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Cancer in Pregnancy
Ayshini Samarasinghe, Mahmood I Shafi
iii
iv
JPOG MAR/APR 2015
GYNAECOLOGY
CONTINUING
MEDICAL EDUCATION
69
81
Hysterectomy for Benign Gynaecological

Disease
Adolescent Menstrual Problems
REVIEW ARTICLE
Despite the advent of newer, and

in some instances less invasive,
interventions for the management
of abnormal uterine bleeding,
hysterectomy remains the most
commonly performed major
gynaecological operation. It continues
to score highest in satisfaction rates. It is therefore imperative that
all aspects of this operation are reviewed on a regular basis.
1 POINT
The most common menstrual problems seen in paediatric

and adolescent gynaecology (PAG) clinic include
dysmenorrhoea, heavy menstrual bleeding, oligomenorrhoea
and amenorrhoea. The incidence of the menstrual problems
seen in PAG clinic varies between countries. This article
reviews different symptoms and potential treatment options.
Nik Rafiza Afendi, Symphorosa Shing Chee Chan
Sahana Gupta, Isaac Manyonda
JPOG welcomes papers in the

following categories:
Review Articles
Comprehensive reviews providing the latest clinical information

on all aspects of the management of medical conditions affecting
children and women.
Case Studies
Interesting cases seen in general practice and their management.
Pictorial Medicine
Vignettes of illustrated cases with clinical photographs.

For more information, please refer to the Instructions for Authors
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The Cover:
Hair Loss in Infancy and Childhood
2015 MIMS Pte Ltd
Ryan R.A. Baranda, Designer
JOURNAL WATCH
PEER REVIEWED
JPOG MAR/APR 2015
of hearing aid use with speech and language outcomes among 180 3- and
5-year-old children with hearing loss. All
Paediatrics
bar four of the children had been fitted

with hearing aids.
Gains in hearing ability for speech
Children with mild hearing

loss also benefit from the use
of hearing aids
provided by the hearing aids were significantly, but modestly, correlated with levels of speech and language in children
with mild as well as moderate-to-severe
hearing loss. Increased duration of hearing aid use was associated with greater
benefits for both speech and language
development.
The researchers conclude that their
findings support the early provision of
well-fitted hearing aids for all children
with hearing loss, even those with mild
impairments.
Tomblin JB et al. The influence of hearing aids on the speech
and language development of children with hearing loss.
JAMA Otolaryngol Head Neck Surg 2014;140:403409.
cy was accountable for the deaths of

three children, all of whom had radiological and histological evidence of
Post-mortem serum vitamin D

valuable for assessing sudden
deaths in children
rickets. Two of these children were

babies who also had cardiomyopathy
and the other, a 3-year-old child, had
hypocalcemic seizures. Twenty-four
Post-mortem assessment of serum vi-
children had insufficient vitamin D lev-
tamin D levels may be valuable when
els (2549 nmol/L), and eight of these
Hearing aids are important tools for fa-
evaluating sudden unexplained deaths
showed abnormal histology. A further
cilitating speech and language develop-
in children, according to a recent report
10 children had suboptimal levels of
ment among children with hearing loss,
by UK researchers.
vitamin D (5079 nmol/L).
but to date few empirical studies have
Their retrospective analysis of post-mor-
The researchers concluded that
evaluated their effectiveness in children
tem findings from 52 children aged 2
low vitamin D may be a significant risk
with mild-to-severe hearing loss. Howev-
days to 10 years found that most had
factor in a variety of morbidities and
er, a recent US-based study has shown
low vitamin D levels, irrespective of their
that postmortem assessment of vita-
that children with both mild and severe
ethnic group.
min D levels may be valuable, particu-
hearing loss benefit from early provision

of hearing aids.
Of the 52 cases assessed, just

one had adequate serum vitamin D lev-
The observational, cross-sectional
els (80 nmol/L). Seventeen children
study was part of the multicenter, longi-
were considered vitamin D deficient
tudinal Outcomes of Children with Hear-
(<25 nmol/L), 10 of whom showed
ing Loss trial, and examined associations
abnormal growth plate histology. Hy-
between aided hearing levels and length
pocalcemia due to vitamin D deficien-
larly as these are stable and easy to

measure.
Scheimberg I and Perry L. Does low vitamin D have a role in
pediatric morbidity and mortality? An observational study of vitamin D in a cohort of 52 postmortem examinations. pediatric
and developmental pathology 2014;17:455464.
45
46
GYNAECOLOGY
JOURNAL
WATCH
JPOG MAR/APR 2015
Oral immunotherapy effective

at desensitising children
with peanut allergy
PEER REVIEWED
placebo-controlled food challenge (DB-
were assessed among 2,455 partici-
PCFC) were randomly assigned to the
pants (53% girls) at a baseline visit at
active (n=49) or control (n=50) arms of
age 10 and again at a follow-up visit at
the trial.
age 13. Dairy intake was assessed by
The primary outcome of desensiti-
3-day food diaries completed before
sation, which was defined as a negative
each visit and was categorised as re-
peanut challenge (1,400 mg protein in a
duced- or full-fat.
DBPCFC) at 6 months, was recorded in
Comparison of participants cat-
62% of children in the active group and
egorised into the highest and lowest
none of the children in the control group;
quartiles of total dairy consumption at
84% of the active group tolerated daily
age 10 years indicated no increased
ingestion of 800 mg protein (equivalent
risk of TBFM (odds ratio [OR] 0.73,
to roughly 5 peanuts). When the control
95% confidence interval [CI] 0.461.16)
participants subsequently underwent the
or overweight (OR 0.69, 95% CI 0.41
same oral immunotherapy regimen, 54%
1.15) at age 13 among those with the
tolerated a 1,400 mg challenge (equiva-
highest levels of dairy consumption.
lent to roughly 10 peanuts) and 91% tol-
Comparison of children in the highest
erated daily ingestion of 800 mg protein.
and lowest quartiles of full-fat dairy in-
The median increase in peanut threshold
take revealed a reduced risk of excess
after therapy was 1,345 mg (range 45
TBFM (OR 0.64, 95% CI 0.411.00) and
1,400 mg). Side effects were mild in most
a reduction in the risk of overweight
participants, but the researchers caution
(OR 0.65, 95% CI 0.401.06) among
that immunotherapy should not be per-
those with the greatest consumption of
formed in a non-specialist setting.
full-fat dairy products. Moreover, chil-
Anagnostou K et al. Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children
(STOP II): a phase 2 randomised controlled trial. Lancet
2014;38312971304.
dren who consumed the most full-fat

dairy products had the smallest gains
in BMI compared with those who consumed fewer such products (2.5 kg/m2
Oral immunotherapy with peanut flour

is effective in desensitizing children with
peanut allergy, say UK-based researchers.
The phase II, randomised, con-
vs 2.8 kg/m2). No significant changes
Dairy consumption at age 10 not

related with excess fat
in late childhood
trolled, crossover trial performed at the

NIHR/Welcome Trust Cambridge Re-
Total and full-fat dairy consumption at
search Facility compared the efficacy of
age 10 is not associated with excess fat
active oral immunotherapy using peanut
accumulation during early adolescence,
flour (with gradual up dosing from 2800
say researchers from the Avon Longitu-
mg/day in two-week increments followed
dinal Study of Parents and Children.
by a maintenance period at the highest
The population-based, prospec-
tolerated dose) and peanut avoidance
tive, cohort study was designed to
for 26 weeks. A total of 99 children aged
examine associations between envi-
716 years who had an immediate hy-
ronmental factors and the health and
persensitivity reaction after peanut inges-
development of children. Mean body
tion, a positive skin prick test to peanuts,
mass index (BMI), total fat body mass
and who were positive by double-blind,
(TFBM), and prevalence of overweight
were observed based on reduced-fat

dairy consumption.
Bigornia SJ et al. Dairy intakes at age 10 years do not adversely affect risk of excess adiposity at 13 years. J. Nutr.
2014;144:10811090.
G
Gynaecology
Fracture incidence can occur
early after therapy for breast or
gynaecological cancer
JOURNAL WATCH
PEER REVIEWED
JPOG MAR/APR 2015
to be similar to that of the general pop-
no cost. The remaining 28% chose to
ulation, with the most common fracture
use another method of contraception.
sites being the vertebrae (16%), feet and
The participants were followed for 23
toes (15%), ribs (12%), hands and fin-
years. Data on pregnancy, birth, and
gers (10%), and pelvis (8%). Interesting-
induced-abortion rates from this cohort
ly, the time to fracture ranged from within
were subsequently compared with na-
the first year through to five years after
tional statistics on sexually experienced
therapy. The median time to fracture was
US teenagers of the same age.
significantly shorter among patients older than 70 years (1.2 years), compared
with those aged 5059 years (3.2 years).
Hui SK et al. Spatial and temporal fracture pattern in breast
and gynecologic cancer survivors. Journal of Cancer
2015;6:6669.
O
Obstetrics
Provision of free education,
contraception can reduce
unintended teen pregnancies
Women who undergo cancer therapy
Pregnancy, birth, and abortion rates can
are known to be at increased risk of frac-
be reduced if teenage girls are provid-
ture. Now, a recent US-based study has
ed with free contraception and educa-
shown that contrary to popular belief,
tion about the benefits of long-acting
fractures may occur early after therapy,
reversible
especially among elderly survivors.
to researchers from the contraceptive
The retrospective study assessed
contraception,
according
CHOICE project.
cohort
Between 2008 and 2013, the
cancer treatment among 139 women di-
study was designed to reduce the inci-
mean annual rates of pregnancy, birth,
agnosed with breast (n=87) or gynaeco-
dence of unintended pregnancy among
and abortion were 34.0, 19.4, and 9.7
logic cancer (n=52) between 2003 and
girls and women in the St. Louis region
per 1,000 teenage participants in the
2012; 56% received chemotherapy, 63%
of Missouri, United States. A total of
CHOICE study. In contrast, national
radiation, and 45% hormonal treatment.
1,404 teenage girls and women aged
rates of pregnancy, birth, and abortion
Fracture data were retrieved from elec-
1519 years were enrolled in this part
among sexually experienced teens of
tronic medical records and were com-
of the project, 72% of whom selected
the same age were 158.5, 94.0, and
pared with skeletal fracture patterns previ-
an intrauterine device or implant after
41.5 per 1,000 in 2008.
ously reported for the general population.
being educated about long-acting re-
pattern
versible contraception and offered their
the removal of financial and access
among the cancer patients was found
choice of reversible contraception at
barriers to contraception and educa-
fracture sites and time to fracture after
The
skeletal
fracture
This
large,
prospective
47
48
GYNAECOLOGY
JOURNAL
WATCH
JPOG MAR/APR 2015
PEER REVIEWED
tion regarding the efficacy of reversible
with persistent and late onset rash was
and psychological outcomes (Hedges
contraception are effective methods
also poorer than that of children with-
g=0.59, 95% CI 0.380.80, p<0.001).
for reducing the number of unintended
out rash. Maternal anxiety and depres-
Effects on psychological outcomes were
teenage pregnancies.
sion, particularly when the child was
generally greater for women, but only
age 8, was found to account for the as-
significantly so for depressive symp-
sociation with internalising symptoms
toms. Greater improvements in preg-
as well as partly for the association
nancy rates were associated with larger
with externalising symptoms in these
reductions in anxiety. Although no signif-
children.
icant difference was observed between
Secura GM et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014;371:1316
1323.
Maternal anxiety,
depression mediate the
association between childhood
eczema or asthma and child
mental wellbeing
Maternal mental health appears to medi-
the effects of cognitive-behavioral thera-
treatment to improve maternal mental
py (CBT), mind-body interventions, and
health may optimise the wellbeing of
other types of psychological interven-
children with asthma and eczema.
tion, CBT appeared to be most effective.
Teyhan A et al. Child allergic symptoms and mental well-being: the role of maternal anxiety and depression. J Pediatr
2014;165:592599.e5.
Frederiksen Y et al. Efficacy of psychosocial interventions for

psychological and pregnancy outcomes in infertile women
and men: a systematic review and meta-analysis. BMJ Open
2015;5:e006592.
ate the relationship between childhood

symptoms of eczema or asthma and the
mental wellbeing of the affected child,
say researchers.
They measured the mental health
of 7,250 children and their mothers
Psychological interventions
improve pregnancy rates
in infertile couples
from the Avon Longitudinal Study of

Parents and Children. Maternal anxiety
Infertile couples treated with assisted re-
and depression were reported during
productive technology may benefit from
pregnancy and when the child was 8
psychological interventions as a recent
years old; child mental wellbeing was
meta-analysis has shown that pregnan-
measured at age 8 years using the
cy rates are almost twice as high among
Strengths and Difficulties Question-
infertile women who receive some form
naire. Individuals were identified as
of psychological intervention compared
having internalising (anxious/depres-
with standard care.
sive) or externalising (oppositional/
Researchers searched the PsycIN-
Childhood
FO, PubMed, EMBASE, CINAHL, Web
rash and wheeze were categorized as
of Science, and Cochrane Library data-
none, early onset (during infancy/
bases for studies published in English
preschool only), persistent (during in-
between 1978 and April 2014 that quan-
fancy/preschool and at school age), or
titatively evaluated the effect of a psycho-
late onset (at school age only).
social intervention on clinical pregnancy
hyperactive)
problems.
Compared with those with no
and/or distress in infertile participants.
wheeze symptoms, children with per-
They identified 39 eligible studies that
sistent wheezing symptoms showed
collectively included 3,401 men and
high externalising and internalising
women.
problems. However, these associa-
Psychosocial
interventions
were
tions were mediated by maternal men-
found to significantly affect both clinical
tal health and disruption of the childs
pregnancy (risk ratio 2.01, 95% confi-
sleep. The mental wellbeing of children
dence interval [CI] 1.482.73, p<0.001)
Con
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The Synthesis of
Evidence, Experience,
and Choice in
Womens Health
Call for Abstracts, Registration,
and Programme at
www.sicog2015.com
PAEDIATRICS
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JPOG MAR/APR 2015
Hair Loss in Infancy

and Childhood
Caroline Champagne,
MBChB MSc MRCP;
Paul Farrant,
MBBS BSc FRCP
Hair problems in children are not uncommon and can cause considerable
anxiety among parents and children. Conditions such as alopecia areata and
trichotillomania can present in both adults and children but in children one also
needs to consider rarer congenital and hereditary causes of hair loss which can
occasionally present as part of a multisystem syndrome. A practical approach to
evaluating hair disorders in children is crucial to ensure the correct diagnosis is
made.
INTRODUCTION
sionally present as part of a multisystem
Hair problems in children are not uncom-
syndrome. A practical approach to eval-
mon and can cause considerable anxiety
uating hair disorders in children is crucial
among parents and children. Conditions
to ensure the correct diagnosis is made.
such as alopecia areata and trichotillomania can present in both adults and
NORMAL HAIR GROWTH
children but in children one also needs
During embryological development the
to consider rarer congenital and heredi-
first hair follicles start to appear at about
tary causes of hair loss which can occa-
9 weeks of gestational age and these
49
50
PAEDIATRICS
JPOG MAR/APR 2015
PEER REVIEWED
up to this stage is synchronised but beyond the

neonatal period hair follicles cycle independently.
Through childhood there is a gradual transition
from vellus (soft, short, unmedullated and usually
non-pigmented) to intermediate and then terminal
Infundibulum
hairs (longer, coarser, medullated and pigmented).
Sebaceous gland
Pili muscle
Isthmus
EVALUATION OF A CHILD
WITH HAIR LOSS
History
It is important to establish whether hair was normal at birth, when hair loss began and whether
this was diffuse loss, patchy loss or failure to
grow. Symptoms such as itch or burning are often
associated with inflammation (rare) or infection or
infestation (both common). Details of teeth and
Outer root sheath
Dermal sheath
Hair bulb
Inner root sheath

Matrix
nail development should be ascertained as well

as problems with heat and sweating if an ectodermal dysplasia is suspected. Other cutaneous
lesions and rashes may be important as well as
the general health of the child and achievement
Dermal papilla
of developmental milestones. A family history of
Figure 1. Schematic Diagram of Basic Components of the Hair Follicle.
hair problems is likely to be relevant in inherited

conditions but is also important when considering
infective causes such as tinea capitis.
are fully established by 22 weeks. The follicle is

conventionally divided into two regions: the upper
Clinical Evaluation
permanent part comprising the infundibulum and
Clinical evaluation should include an assessment
isthmus and the lower cycling (growing and then
of the pattern and extent of hair loss. If a patchy
regressing) part consisting of the hair bulb and
alopecia is apparent it is important to determine
suprabulbar region (Figure 1).
whether there are patent follicular ostia or wheth-
Hair follicle stem cells reside in the bulge re-
er these are lost suggesting a scarring condition.
gion of the isthmus. Evidence suggests that the
Signs of inflammation such as peri-follicular ery-
lower part of the hair follicle is an immunologically
thema, follicular hyperkeratosis, pustules or swell-
privileged site not subject to typical immune sur-
ing should be sought. Any abnormalities in the
veillance. During the hair cycle the growth phase
skin, nails and teeth should be noted as well as
anagen is followed by an involution phase cata-
any syndromic features. The hair pull technique
gen and then a resting phase telogen (Figure 2).
can be used to assess hair shedding in general-
The hair is then eventually shed through an active
ised hair loss as well as disease activity in focal
process called exogen.
conditions. The number and type of hairs extract-
Lanugo hair is shed about 1 month before
ed may give clues to the underlying diagnosis
birth and most hairs re-enter the anagen growth
(Table 1). Anagen hairs have a pigmented bulb
phase but in the occipital scalp telogen is delayed
enclosed within its root sheath whereas telogen
until after birth which may give rise to a patch of oc-
hairs have a de-pigmented club shaped bulb
cipital hair loss in the neonatal period. Hair cycling
(Figure 3). A modified hair pull test can be used to
PAEDIATRICS
PEER REVIEWED
JPOG MAR/APR 2015
assess hair breakage.
Microscopy and Scalp Biopsies

Light microscopy of hairs trimmed at their bases
should be used for the investigation of possible
Anagen
90% scalp hair, 2.5 years

(Growing phase)
Catagen
(Regression phase)
hair shaft disorders. Abnormal hair fibre production can produce unruly hair due to hairs being ir-
Sebaceous gland
regularly shaped, spangled hair where hair twists

reflect light at variable angles and fragile hair. Hair
hair loss occur due to breakage of structurally
Epithelial column
3 months
fragility can lead to localized or diffuse areas of
Hair matrix
Dermal papilla
weak hair. Hair shaft disorders are divided into
Exogen
those with or without increased fragility. Scanning
Telogen
(Exit phase)
electron microscopy will provide even more de-
10% of scalp hairs

(Resting phase)
tailed images of the hair shaft but expertise and

availability limits its use. Scalp biopsies sent for
Old club hair
both horizontal and vertical sectioning may give

useful clues to the underlying cause but requires
at least two biopsies, can be challenging and ideally should be avoided in children if possible.
HAIR DISORDERS IN INFANCY

Aplasia Cutis Congenita (ACC)
This condition is characterised by areas of absent
Figure 2. Stages of the Hair Cycle.
or scarred skin from birth. It reflects disruption of

interuterine skin development and potential causes include vascular compromise, trauma, inter-
Table 1. Potential Hair Pull Findings
uterine infection or teratogenic medication. It may

be incorrectly attributed to obstetric trauma such
Condition
Positive Hair Pull Findings
as forceps or fetal scalp electrodes. A solitary ero-
Telogen effluvium
Increased telogen hairs extracted

from all areas
Alopecia areata
Increased telogen hairs or dystrophic

hairs from affected areas
Primary scarring alopecias
Increased anagen hairs extracted
Loose anagen syndrome
Painless extraction of dysplastic

anagen hairs (may lack root sheath
and have a hockey stick appearance)
sion, deep ulceration or scar affecting the scalp is

the most common form. These lesions are usually
located on the vertex of the scalp lateral to the
midline and vary in size from 1 to 10 cm in diameter. Distorted hair growth around the lesion is
known as the hair collar sign. The abnormality is
usually limited to the epidermis and dermis. Most
lesions heal spontaneously within a few months
leaving hairless scars which generally become
less noticeable as the child grows.
or oval patch of alopecia in the fronto-temporal region (Figure 4). Most are
Temporal Triangular Alopecia
unilateral with the base of the triangle orientated forwards and fine vellus
This is a relatively common non-scarring form
hairs are present in the affected area. Due to the location and typical lancet
of alopecia. The majority present around 2 to 6
shape the diagnosis of triangular alopecia is usually easily made clinically,
years of age with a well-circumscribed triangular
with alopecia areata being the main differential.
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PAEDIATRICS
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Ectodermal Dysplasias (ED)

These are a group of inherited developmental
syndromes with abnormalities in at least two of
the major ectoderm derived structures. Mostly infants will present with abnormalities in hair, nails,
skin, teeth and eccrine glands but ED can be associated with other abnormalities such as deafness, mental retardation, skeletal abnormalities
and distinctive facies.
The alopecia can be due to hypotrichosis or hair shaft defects with increased fragility. Eyebrows and eyelashes may be involved.
Nails may be absent (anonychia), thickened or
dystrophic and teeth can have enamel defects
causing hypodontia, adontia or peg-shaped
incisors. Defective sweating and impaired thermoregulation results from abnormalities of the
eccrine glands.
Telogen
Anagen
Figure 3. Telogen Hair with De-pigmented Bulb and Anagen Hair Showing
Pigmented Bulb Enclosed Within its Root Sheath.
MY CHILDS HAIR WONT GROW

Hypotrichosis
Hypotrichosis is a common feature of many
inherited syndromes and the hair is not only
Occipital Neonatal Alopecia
sparse but often structurally abnormal as well.
This common form of alopecia develops in the
It is common for hair to be present at birth or
occipital region in the first few months of life
in infancy and then thin with age. Hypotrichosis
(Figure 5). It occurs due to alterations in hair cy-
simplex is an autosomal dominant condition not
cling. Unlike hairs at other sites the occipital hairs
associated with other syndromes where the hair
dont move into telogen until after birth and there-
thins progressively during childhood to become
fore shedding in this area commonly occurs 2 to
almost absent by early adulthood. The profound
3 months later. Friction of the head on the pillow
reduction in the number of hair follicles can be
may contribute to the shedding but the alopecia
generalised or confined only to the scalp. Ma-
will resolve spontaneously.
rie Unna hypotrichosis is an autosomal dominant disorder which presents during childhood
Atrichia Congenita and Atrichia

with Papular Lesions
with hair loss and texture change. Hairs become
Atrichia congenita is a rare condition where there
lost over puberty and early adulthood often in a
is total and permanent absence of scalp hair which
pattern resembling androgenetic alopecia. Other
may begin at birth or hairs can be shed in the first
body hair is typically absent.
coarse, wiry and twisted. It is then progressively
few months with no further growth thereafter. Both

autosomal dominant and recessive variants have
Loose Anagen Syndrome
been described. It can be an isolated phenome-
Anchorage of growing anagen hairs is impaired in
non or associated with other defects such as Atri-
loose anagen syndrome so that hairs can be eas-
chia with Papular Lesions where children develop
ily and painlessly plucked from the scalp. Classi-
small papules on the face, neck and scalp.
cally it occurs in children between 2 and 7 years,
PAEDIATRICS
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is more common in girls and predominantly affects children with fair skin and blond hair. The
hair is normal at birth but later becomes sparse
or fails to grow long. A gentle hair pull will painlessly remove anagen hairs. Light microscopy of
extracted hairs will reveal dysplastic anagen hairs
with misshapen bulbs. This condition may resolve
spontaneously with age.
Short Anagen Syndrome

In this condition the hair does not grow long or
need cutting due to a decreased duration of the
anagen phase. It tends to be first noticed by parents around 2 to 4 years. The hair shaft is normal
without signs of breakage but the anagen phase
is shortened and subsequently there are overall
more telogen hairs. Unlike in loose anagen syndrome the hair pull is normal. Short anagen syndrome tends to improve after puberty.
Hair Shaft Abnormalities

with Increased Fragility
Trichorrhexis Nodosa (TN): is the commonest
hair shaft defect and is a particular response
of the hair shaft to weathering which results in
hair breakage. The cuticular cells are disrupted
causing the cortical cells to fray forming a fragile
node which breaks leaving a paint-brush like tip
(Figure 6). An acquired distal TN occurs in structurally normal hair exposed to excessive trauma
(heat, straightening, chemicals, sunlight etc).
In that situation the hair can be dry, dull or brittle with whitish nodules at the ends. Excessive
physical and chemical trauma must be avoided.
Figure 4. Triangular Alopecia Courtesy of Professor Andrew Messenger, Royal

Hallamshire Hospital.
Monilethrix: this defect of hair keratins is inherited in an autosomal dominant pattern. It results
in beading (wide and narrow zones in the hair
Pili Torti: hairs are flattened and twisted through
shaft) with increased fragility and breakage in the
180o at irregular intervals along the hair shaft
narrow zones (Figure 6). This leads to a stubble
and are fragile (Figure 6). Not all hairs are af-
appearance and the hair tends to be dry and brit-
fected. The twisting creates a spangled appear-
tle. Topical minoxidil and oral retinoids may help
ance and hairs that grow in areas subjected to
and avoidance of behaviours causing excessive
less trauma tend to be unruly. In the classic
weathering is important. There tends to be some
form hair is normal at birth and is then gradually
improvement with age.
replaced by spangled blond hair. At puberty the
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PAEDIATRICS
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PEER REVIEWED
hair darkens and becomes less fragile. Pili torti

can also be a feature of other syndromes such
as Menkes syndrome and several ectodermal
dysplasias.
Trichorrhexis Iinvaginata: Trichorrhexis invaginata (bamboo hair - Figure 6) is a feature of Nethertons syndrome and is associated with a distinctive rash, ichthyosis linearis circumflexa. This
is an autosomal recessive condition with variable
expression that affects girls more than boys. It results from mutations in the SPINK5 gene which
encodes the serum protease inhibitor protein LEKTI and associated atopy is common. The hair
Figure 5. Occipital Alopecia Courtesy of Professor Andrew Messenger, Royal
Hallamshire Hospital.
abnormality usually becomes noticeable in infancy with the development of short, sparse, brittle
and fragile hair. The eyebrows and eyelashes are
usually sparse or absent. Light microscopy will
show areas where the distal hair shaft invaginates
into the proximal hair shaft. The hair may improve
with age as the follicles thicken but defects in eyebrow and body hair tend to persist.
MY CHILD HAS UNRULY HAIR

Hair Shaft Abnormalities without
Increased Fragility
Pili Annulati: this condition is characterised by hair
shafts that have alternating light and dark bands
Monilethrix
Trichorrhexis
Invaginata
caused by air cavities in the cortex. Patches of hair

have an attractive spangled appearance. It may be
sporadic or inherited in a dominant fashion. Uncombable hair (Cheveux incoiffables, pili trianguli et canaliculi, spun glass hair): this is an autosomal dominantly inherited disorder characterised by triangular
hairs (Figure 7). The abnormality may first become
apparent between 3 months and 12 years of age.
While normal in quantity and length the hair is unruly with a disordered appearance and resists being
combed flat. The hair is often silvery blond in colour and typically more than 50% of the scalp hairs
Pili torti
Trichorrhexis
Nodosa
Figure 6. Hair Shaft Abnormalities with Increased Fragility.
are affected. On light microscopy the hairs have a

triangular shape on cross section with a longitudinal groove. The appearance tends to become less
marked and the hair more manageable with age.
Uncombable Hair (Cheveux incoiffables, pili tri-
PAEDIATRICS
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Figure 7. Uncombable Hair Showing Triangular Hairs on Microscopy and Unruly Spun Glass Hair.
acterised by triangular hairs (Figure 7). The ab-
MY CHILDS HAIR KEEPS

COMING OUT
Telogen Effluvium
normality may first become apparent between
Scalp hair loss due to increased telogen hair
3 months and 12 years of age. While normal in
shedding can be acute occurring after a trigger-
quantity and length the hair is unruly with a dis-
ing event with spontaneous complete regrowth
ordered appearance and resists being combed
or chronic if the insult is prolonged or repeated.
flat. The hair is often silvery blond in colour and
There is usually a two to three month delay be-
typically more than 50% of the scalp hairs are
tween insult and hair shedding. Common triggers
affected. On light microscopy the hairs have a
in children include high fever/ infections, physi-
triangular shape on cross section with a longitu-
cal and emotional stress, sudden starvation and
dinal groove. The appearance tends to become
certain drugs but in a third of cases no trigger is
less marked and the hair more manageable with
found. Unless the trigger is repeated the shed-
age.
ding stops and regrowth occurs by 3 to 6 months.
anguli et canaliculi, spun glass hair): this is an

autosomal dominantly inherited disorder char-
Scalp hair loss due to increased telogen hair shedding can

be acute occurring after a triggering event
Woolly Hair: this is tightly coiled hair covering
A hair pull test reveals hairs in telogen phase
all or part of the scalp occurring in non-African
throughout the scalp.
individuals. Some patients present with a circum-
Hair shedding may be more chronic in chil-
scribed patch of woolly hair (woolly hair naevus).
dren with thyroid disorders, iron deficiency anae-
Generalised woolly hair can be inherited as an
mia, acrodermatitis enteropathica (acquired zinc
autosomal dominant or recessive trait. Hairs are
deficiency), malnutrition, malignancy, drugs and
fine and of irregular caliber and as well as coil-
autoimmune disorders such as systemic lupus
ing, knots and fractures are common. The triad of
erythematosus and dermatomyositis. The history
woolly hair, palmar-plantar keratoderma and car-
may identify a known trigger but investigations
diomyopathy may indicate either Naxos disease
should include full blood count, electrolytes, liv-
or Carvajal disease.
er function, thyroid function, ferritin/iron studies,
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PAEDIATRICS
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PEER REVIEWED
Figure 8. Patchy Alopecia Areata.

serum zinc levels and antinuclear antibodies. If a
salis, AU). Poor prognostic features include onset
drug is thought to be the culprit this should be
of AA prepuberty, severe disease at presentation,
stopped for at least 3 months.
ophiasis pattern of alopecia (band like loss over

the occipital scalp), nail involvement and associ-
Loose Anagen Syndrome

(See above).
ated atopic disease.

The characteristic presentation of AA is the
development of well-circumscribed, totally bald,
Alopecia Areata
smooth patch of alopecia on the scalp (Figure 8).
(See below).
Other presentations include AT, AU, ophiasis pattern and rarely a diffuse variant with widespread
MY CHILD HAS DEVELOPED NEW

PATCHES OF HAIR LOSS
Alopecia Areata
thinning. The eyebrows and eyelashes are lost
This non-scarring form of alopecia is considered
first. Often exclamation-mark hairs (dystrophic
to be an autoimmune disorder and failure of im-
hairs with fractured tips) are present as well as
mune privilege plays an important role in the
cadaverised hairs (hairs fractured before passing
pathogenesis. A genetic predisposition is also
through the scalp). A hair pull can reveal telogen
suggested as about 20% of people with AA have a
or dystrophic anagen hairs.
in many cases and may be the only sites affected. Regrowth can be fine and depigmented at
family history of the disease. Inflammation targets
The management of AA is dependent on
anagen hairs causing dystrophic anagen hairs
the extent of the disease and on the psycholog-
and transition to telogen phase.
ical impact it is having on the child and the fam-
In patchy alopecia spontaneous recovery
ily. Referral to a paediatric psychologist may be
can occur in up to 80% within one year. 14 to 25%
needed to find coping mechanisms and prevent
progress to total loss of scalp hair (alopecia tota-
social and educational disruption. Leaving AA
lis, AT) or loss of entire body hair (alopecia univer-
untreated is a legitimate option especially when
PAEDIATRICS
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spontaneous remission is possible or when effective treatments are unlikely to be tolerated well. In
such situations a wig, headscarf and semi-permanent tattoos can be helpful. In limited patchy
hair loss potent topical steroids with or without
occlusion and intralesional steroids may induce
hair growth but can cause skin atrophy. Discomfort from injections restricts its use in young
children. For more extensive patchy hair loss
or AT/AU systemic corticosteroids can produce
regrowth but this is often not sustained and the
risks may outweigh the benefits. Contact immunotherapy has been shown to be effective but is
not widely available and can be difficult and disruptive in young children as it needs to be repeated frequently (weekly).
Trichotillomania
This is a behavioural disorder characterised by
compulsive hair pulling or plucking. It occurs in
two main forms. In infants and young children it
represents a habit tic similar to thumb sucking.
It is more common in boys and usually resolves
spontaneously. In older children and adolescents
it is seen predominantly in females often with evidence of psychological or behavioural stress.
This form is characterised by the American Psychiatric Association as an impulse control disorder where irresistible hair pulling results in release
of tension and distress. Hair is most commonly
Figure 9. Tinea Capitis Courtesy of Dr Elisabeth Higgins, Kings College Hospital,

London.
plucked from the fronto-temporal regions of the

scalp and results in patches of hair loss with irreg-
of the scalp in children. The causative organisms
ular borders containing hairs of variable length.
are the Trichophyton and Microsporum species.
The extent of alopecia can vary but it is unusual
Currently Trichophyton tonsurans is the com-
for hair to be lost completely.
monest pathogen in the UK especially in urban
A confident clinical diagnosis is essential but
areas but the epidemiology varies worldwide. The
may not always be easy and might require ob-
Trichophyton species cause an endothrix infec-
servation overtime. In young children it is usually
tion (fungal spores within the hair shaft) which
self-limiting. Management in adolescents is more
does not fluoresce under UV light but hair shaft
challenging. Those with insight should be re-
damage causes hairs to break off close to the
ferred to psychological services for habit reversal
scalp surface creating a black dot appearance.
and potentially pharmacological therapy.
Microsporum canis, another common pathogen,

causes an ectothrix pattern (fungal spores formed
Tinea Capitis
around the hair shaft) which fluoresces bright
Tinea capitis is a common dermatophyte infection
green with UV light.
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Practice Points
PEER REVIEWED
Scarring Alopecia
Establish the principle complaint: diffuse or patchy hair loss, hair

shedding, poor growth or breakage.
Determine whether there are signs of inflammation or scarring.
A dermatologist may use the hair pull technique, light microscopy
and occasionally scalp biopsies to aid the diagnosis of more
complex cases.
Abnormalities in hair shaft production can produce fragile hair
where breakage may cause either localised or diffuse areas of
hair loss.
A common cause of hair shedding is acute telogen effluvium,
which occurs two to three months after a triggering event.
Alopecia areata characteristically produces well-circumscribed
non-scarred patches of hair loss.
The features of tinea capitis vary from scaly patches of alopecia
to a boggy swelling or kerion formation and oral antifungal agents
are required after diagnostic hair samples/skin scrapes are taken.
Scarring or cicatricial alopecia implies permanent hair loss associated with destruction of
hair follicles. This can result from a disease that
affects the follicles primarily or a secondary external process. Examples of secondary causes
include burns, radio-dermatitis, morphoea and
infections such as the favus form of tinea capitis. Primary scarring alopecia in children is extremely rare. In African American girls traction
alopecia can result in a permanent alopecia if
traction from hair styling is excessive and prolonged. Initially however the hair loss is temporary and behaves like a non-scarring alopecia.
CONCLUSION
An understanding of the basic hair biology
improves the assessment of a child with hair
problems and helps to explain why some
The clinical features may vary from a relative-
congenital disorders do not present until later
ly noninflammatory patchy alopecia, with or with-
in childhood. Approaching a hair disorder in
out scale, to an inflamed boggy lesion with pus-
children according to the principle complaint,
tules and abscess formation, known as a kerion.
be it patches of hair loss, hair shedding, poor
Discrete patches are the commonest presenta-
growth or hair breakage is more likely to lead
tion (Figure 9). Many children have associated
to a diagnosis. An ability to recognise both the
lymphadenopathy.
common and rarer hair conditions will ensure
Scalp scrapings or hair brushings sent for

microscopy and culture are important to confirm
early access to correct management for these

distressing conditions.
the diagnosis. Oral antifungal agents are needed to ensure eradication but combined use with
topical treatment such as ketaconazole shampoo
may reduce the risk of transmission. Although
not licensed in children, oral terbinafine is generally recommended as it is particularly effective
for the Trichophyton species. It is fungicidal and
the duration of treatment (2 to 4 weeks) is shorter
than griseofulvin, a fungistatic agent. For infection
with Microsporum species however griseofulvin
Further Reading
1. Farrell A, Sinclair R, Dawber R. Disorders of the hair and scalp.

Fast facts. Health Press Limited, 2000.
2. Fuller LC, Barton RC, Mohd Mustapa MF, et al. British Association of Dermatologists guidelines for the management of tinea
capitis 2013. Draft update from: Higgins EM, Fuller LC, Smith CH.
Guidelines for the management of tinea capitis. Br J Dermatol
2000;143:5358.
3. Messenger AG, de Berker DAR, Sinclair RD. Disorders of hair. In:
Burns T, Breathnach S, Cox N, Griffiths C, eds. Rooks textbook of
dermatology. 8th edn, vol. 4. Wiley-Blackwell, 2010. p66.166.75.
4. Messenger AG, McKillop J, Farrant P, et al. British Association of
Dermatologists guidelines for the management of alopecia areata
2012. Br J Dermatol 2012;166:916926.
5. Sperling L. Alopecias. In: Bolognia JL, Jorizzo JL, Rapini R, et al.,
eds. Dermatology. 2nd edn. Elsevier Limited, 2008;p9871005.
remains the treatment of choice. Combs, brushes, hats etc should be disinfected or discarded
2014 Elsevier Ltd. Initially published in Paediatrics and Child Health

2014;25(2):6671.
and family members must also be examined,

screened and treated accordingly to prevent re-in-
About the Authors
fection. Both clinical and mycological clearance
Caroline Champagne is a specialist registrar in the Dermatology Department. The Churchill Hospital, Oxford, UK. Conflicts of interest:
none. Paul Farrant MBBS BSc FRCP is a Consultant Dermatologist
in the Dermatology Department, Brighton General Hospital, Brighton,
UK. Conflicts of interest: none.
should be confirmed once the standard course of

treatment is completed.
OBSTETRICS
PEER REVIEWED
JPOG MAR/APR 2015
Cancer in Pregnancy
Ayshini Samarasinghe, MBBS BSc; Mahmood I Shafi, MBBCh MD DA FRCOG
A diagnosis of cancer in pregnancy has an incidence of 0.1%. This is expected to

rise with increasing number of women delaying childbearing into later life. Common
malignancies are breast, cervix, leukaemia, lymphoma, melanoma, thyroid, ovary
and colon. Diagnosis and treatment is a complex balance between maternal wellbeing and fetal wellbeing. An individualised treatment plan is crucial, with input from
a multitude of professionals. The advantages and disadvantages of continuing with
the pregnancy should be weighed against the physical and psychological wellbeing
of both the parents and the child, along with the timing of maternal treatment and
timing of delivery.
INTRODUCTION
some malignancy rises with increasing
Cancer in pregnancy is a complex diag-
age, this rare occurrence is likely to be-
nosis that endangers two lives. The oc-
come more common. Diagnosis may of-
currence of cancer in pregnancy is rare,
ten be delayed as physical signs may be
about 1:1,000 pregnancies. However as
masked or attributed to pregnancy-relat-
women delay childbearing to their later
ed symptoms. Diagnosis and treatment
reproductive years and the incidence of
of cancer in pregnancy poses a complex
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OBSTETRICS
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Table 1. Approximate Fetal Absorbed Doses during Imaging Studies
PEER REVIEWED
aging are widely used and relatively safe. X-ray

and CT expose the fetus to radiation. (Table 1) Fetal risks starts from 10 cGy. The risk for childhood
Procedure
Fetal Dose (cGY)
Chest X-ray
0.00006
In staging, fetal protection when ever possible
Abdominal X-ray
0.15-0.26
with abdominal shielding is advised.
Pelvic X-ray
0.2-0.35
Intravenous Pyelography
0.4-09
Barium enema
0.3-4
tially the same as for the non-pregnant state. A
Mammograph
0.01-0.04
holistic approach to treatment is vital, decided by
CT Thorax
0.01-1.3
CT Abdomen
0.8-3
CT Pelvis
2.5-8.9
cancer is highest after abdomino-pelvic imaging.
MANAGEMENT
The thought process for management is essen-
a multidisciplinary team, including system specialists, oncologists, obstetricians, perinatalologists, paediatrician, psychologists, radiologists
and specialist nurses (Figure 1).
TREATMENT
Surgery
challenge of balancing optimal maternal treatment
Overall 0.75 to 2% of pregnant women will un-
and fetal well-being. There is considerable physio-
dergo surgery during pregnancy. Surgery and
logical and psychological impact to both women
anaesthesia are considered safe during pregnan-
and their partners, so a multidisciplinary approach
cy. The patient should be positioned supine with
with a standardised management plan is crucial.
a left lateral tilt. Adequate maternal monitoring is
It also poses a significant challenge to the physi-
crucial in preventing hypoxia, hypotension and
cian due to an absence of large randomised trials,
hypoglycaemia. Data suggests that surgery does
leading to lack of clinical guidance. Additionally
not increase risk of miscarriage, only in cases of
personal concepts such as religious and emotion-
peritonitis was the rate of fetal loss increased.
al beliefs vary from one couple to another.
Open laparoscopic or left upper quadrant tech-
The most common malignancies in pregnan-
nique is preferred, as Verres entry puts the preg-
cy are breast and cervical, followed by leukaemia,
nant uterus at risk. The safest time to undertake
lymphoma, melanoma, colorectal and thyroid.
laparoscopy is the second trimester.
Cancers during pregnancy can be divided

into those originating from the gestational tis-
Systemic Treatment
sue, or those from other tissue. Although some
During pregnancy multiple changes in physiology
cancers may spread to the placenta, most can-
affect the pharmacokinetic processes of drugs.
cers do not spread to the fetus itself. A pregnant
This may have toxic consequences to both the
woman with cancer is capable of giving birth to a
pregnant women and fetus. The potential risk of
healthy term baby. The main problems faced are
chemotherapy agents depends on the gestation
the timing of investigations, treatment and the im-
at exposure.
plications of these on the developing fetus.
At the fertilization and implantation stage (first

10 days) exposure will result in an all-or-nothing
INVESTIGATIONS AND IMAGING

IN PREGNANCY
phenomenon. In the following 8 weeks organo-
As in non-pregnancy staging should be compre-
risks of congenital malformations. In the second
hensive. Ultrasound and magnetic resonance im-
and third trimester no major malformations are ex-
genesis occurs putting the fetus at increased
OBSTETRICS
PEER REVIEWED
JPOG MAR/APR 2015
pected, however cases of growth restriction, pre-
Malignancy
suspected
maturity, intrauterine death and haematopoietic

suppression have been documented. Common
cytotoxic drugs used in gynaecological cancers
include Platin, Paclitaxel, Bleomycin, Etoposide
Need to
confirm diagnosis
and Vinblastin.
Specific cytotoxic drug effects are difficult to
describe as combinations are frequently used.
The decision to administer chemotherapy
Take appropriate
biopsies
should take into account gestational age, however

the same guidelines as for nonpregnant patients
should be followed during the management, for
example, the timing of surgery, radiotherapy etc
Consider
gestational age
Chemotherapy is contraindicated until a gestation

age of 10 weeks due to the increased risk of congenital malformation in the organogensis stage.
Timing of delivery needs to factor in maturation of
Stage with
imaging (MRI)
or surgery as
appropriate
the fetus and oncology treatment schedule. Delivery should be planned at least 3 weeks after the
last cycle of chemotherapy to allow bone marrow
recovery to reduce the risk of haemorrhage and
sepsis.
Supportive and symptom control therapy
can be given according to general recommendations (Table 2). Corticoids, methylprednisolone
and hydrocortisone are extensively metabolized
1st
Trimester
2nd/3rd
trimester
Will termination of
pregnancy aid maternal
management and
improve prognosis?
Will treatment
affect pregnancy?
in the placenta with minimal crossover into the

fetus.
Therapeutic pelvic irradiation induces severe
or lethal consequences to the pregnancy and
should be avoided in ongoing pregnancies.
Thromboprophylaxis
YES
NO
NO
YES
The hypercoagulable state of pregnancy is associated with an increased risk of thromboembolic

disease. This risk is even higher in pregnancy associated with cancer. Treatment and its duration
would need to be decided on an individual basis
Advise mother and

proceed according
to her wishes
Proceed with
treatment
with collaboration with the heamtologists.

Figure 1. Management of Malignancy in Pregnancy.
ORGAN PATHOLOGY
Gynaecological Malignancies
pregnancies. Both cervical glands and stroma
Cervical Cancer: abnormal cervical cytolo-
undergo physiological pregnancy-related chang-
gy complicates about 5% of pregnancies, and
es, which can alter cytologic and colposcopic
the risk of invasive disease is 1 in 4,500 9,000
interpretation, therefore routine cervical cytology
Consider delay of
treatment until fetal
maturity and delivery
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Table 2. Supportive Drugs and Fetal Safety Profile
PEER REVIEWED
lymphadenectomy, neoadjuvant chemotherapy

and trachelectomy. If possible, delaying until after
32 weeks gestation will allow a surgical approach
Medication
Safety
Metoclopramide
Can be used safely at any

gestation
5-HT antagonists
Animal data suggests low risk
caesarean section is undertaken given the risk for
Corticoids
Can be used after first trimester
bleeding and a theoretical risk of tumour emboli-
Granulocyte colony-stimulating
factors
Should not be with held, may

cross placenta
sation during labour.
Eythropoetins
Can be used during pregnancy,

unlikely to cross placenta
Ovarian Cancer: most pelvic masses of ovarian
Paracetamol
Can be used safely
tenatal ultrasound are benign. There is a 1 in a
of caesarean-radical hysterectomy with potential

conservation of ovaries (Figure 2).
Vaginal delivery is possible but generally a
or uterine origin that are found at the time of an1,000 incidence of ovarian tumours in pregnancy. The risk of malignancy of these is 3 to 6%.
The histological presentation is shown in Table
Table 3. Frequency of Ovarian Malignancy in Pregnancy
3. These are more likely to present at an early

stage due to the frequent obstetric ultrasounds
conducted in pregnancy. Management is similar
Histology
Frequency (%)
to the non-pregnant woman, however diagnosis
Germ cell
6-40
poses a problem due to the physiological rise in
Boderline
21-35
Epithilial
28-30
gestation. The probability of developing abdom-
Sex-cord stromal
9-16
inal wall metastasis is higher after laparoscopy
Other
3-5
tumour markers in pregnancy. A laparoscopic approach to surgery is feasible if less than 16 weeks
for cancer than after open surgery. Tumours with

low malignancy potential have good prognosis,
and are treated surgically without chemotherapy.
Stage one neoplasm can be treated with unilat-
is not recommended in pregnancy. Biopsies carry
eral salpingo-ooporectomy, omentectomy and
a significant risk of haemorrhage, but should not
peritoneal washings. For higher stages adjuvant
be delayed if there is a high clinical suspicion of
chemotherapy is advised. In the second and third
invasive disease. In the absence of invasive can-
trimester the standard guidelines for chemother-
cer, treatment is not necessary in CIN 2-3 lesions
apy should be used, as there are no major irre-
during pregnancy. Repeat colposcopy/treatment is
versible consequences for the fetus. Restaging
advised following delivery. In the presence of pre-in-
after delivery should also be considered. In ad-
vasive disease vaginal delivery is permissible.
vanced stage ovarian cancer treatment options
Where there is invasive disease, treatment is

dictated by the gestation age, stage of disease
differ depending on maternal wish, gestation age

and the maternal prognosis.
and wishes of the patient.

Stage one A1 disease is treated by cone bi-
Vulval Cancer: vulval intraepithelial neoplasia can
opsy. Possible complications from a cone biopsy
be treated with laser or surgical excision at any stage
include haemorrhage, miscarriage, premature
in pregnancy with similar principles to the non-preg-
labour, premature rupture of membranes and in-
nant patient. For invasive disease the potential to
fection. For higher stages interventions include
preserve pregnancy depends on nodal staging.
OBSTETRICS
PEER REVIEWED
JPOG MAR/APR 2015
For invasive, node negative cancer a hemi
Colposcopy
during pregnancy
or total vulvectomy and unilateral or bilateral

lymphadenectomy can be considered. Narrow
margins, less than 1 cm should be avoided as
radiotherapy is contraindicated in pregnancy.
Route of delivery needs to be discussed with the
multidisciplinary team. There is increased risk of
haemorrhage at time of surgery due to increased
No suspected
invasion
Suspected
invasion
Serial
colposcopy and
cytology each
trimester
Wedge/cone
biopsy
vascularisation of the pelvis.

For those with positive node involvement
the prognosis is poor. Treatment is advised without delay. Termination and treatment is advocated in the first and second trimester when there is
metastatic inguino-femoral node involvement. In
the third trimester, delivery and standard treatment is recommended. A caesarean section is
preferred to reduce the risk of episiotomy scar
recurrence.
No progression
either
colposcopically
or cytologically
Early invasion
(Stage 1a1) or less
Invasion
confirmed
Await
delivery
Stage and treat

in consultation
with couple and
obstetricians
Endometrial Cancer: endometrial cancer is

rarely associated with pregnancy. The abnormal
endometrium is usually unfavourable to ongoing
pregnancy. The majority of the limited numbers of
case study reports available are following curettage for miscarriage.
Gestational Trophoblastic Neoplasia: this is a
Postpartum
assessment at
three months
and treatment
rare but curable tumour arising from products of

conception. The commonest form is hydatidiform
mole, found in 1 in 1,000 pregnancies. These can
be divided into complete and partial moles. Com-
Figure 2. Cervical Cytological Abnormality or Suspected Malignancy During

Pregnancy.
plete molar pregnancies are diploid and androgenic, with no evidence of fetal tissue. These arise
Human Chorionic Gonadotrophin (HCG) levels
from fertilisation of an empty ovum with a single
are used to monitor patients following surgical
sperm. Partial moles are formed following dis-
evacuation. Follow up is undertaken at special-
permic fertilization of an ovum and are triploid in
ised screening centres, if HCG levels have re-
origin. There is usually some evidence of a fetus
verted to normal within 56 days of the pregnancy
or fetal red blood cells in a partial molar pregnan-
event, follow up is for 6 months from the date of
cy. Both complete and partial molar pregnancies
evacuation. If the HCG hasnt reverted to normal
can develop into choriocarcinoma. Complete hy-
within 56 days then follow up is for 6 months after
datidiform mole can also develop into placental
normalisation of HCG levels. There is no evidence
trophoblastic tumours. Primary treatment is with
of reactivation of disease in subsequent pregnan-
evacuation of the products of conception within
cies. However patients who have had 1 disease
the uterus. About 15 to 20% of complete moles
episode are at greater risk for development of
and 0.5% of partial moles require chemotherapy.
a second episode in a subsequent pregnancy.
63
64
OBSTETRICS
JPOG MAR/APR 2015
PEER REVIEWED
age group. The incidence in pregnancy is about
Breast lump
in pregnancy
1 in 3,000. There may be a delay in diagnosis due

to the physiological changes within the breast
tissue during pregnancy. Genetic and environmental risk factors are similar to the non-pregnant
Imaging
(Ultrasound,
mammography)
and core biopsy
population. The presence of BRCA1 or BRCA2

mutation increases the risk of developing breast
cancer in both the pregnant and non-pregnant
patient equally. Breast ultrasonography and MRI
can be used safely in pregnancy. Physiological
hyperproliferative changes of the breast can lead
Staging: liver US,

chest x-ray, MRI
to false positive or false negative results with

fine-needle aspiration cytology and is therefore
<12/40
Locally advanced
>12/40
Not locally advanced
not recommended. Sentinel node procedures

Locally advanced
can be safely performed, though due to the risk

of maternal anaphylaxis, blue dye is avoided in
pregnancy. Treatment depends on the gestation
Consider
termination and
standard treatment
Breast conserving
surgery or mastectomy,
sentinal node procedure
or axillary node dissection.
Adjuvant chemotherapy
from 14 weeks onwards.
Radiotherapy is not
considered until
after delivery
Neoadjuvant
chemotherapy
of pregnancy (Figure 3).

Bisphosphonates are not used in pregnancy
due to maternal toxicity, fetal underdevelopment,
hypocalcaemia and skeletal retardation shown
in animal studies. Hormonal agents such as selective oestrogen receptor modulators are used
following delivery. Tamoxifen use is also contraindicated due to its association with birth defects
such as craniofacial malformations, ambiguous
Deliver
>3537/40
genitalia and fetal death.

Haematological Malignancies: Hodgkins Lymphoma is the most common, followed by non-
Completion
of treatment
Figure 3. Management of Breast Lump in Pregnancy.
Hodgkins Lymphoma (NHL) and acute leukaemia. The treatment depends on the type of cancer
and the gestational age (Table 4).
Lymphoma: with a prevalence of 1 in 6,000 pregnancies, lymphoma is the fourth most common
Patients are advised to delay conception for one
cancer in pregnancy. The signs such as shortness
year after chemotherapy to allow monitoring with
of breath and tiredness can easily be confused
HCG. The pregnancy rate is more than 83% fol-
with those found in normal pregnancy. Diagno-
lowing treatment, and HCG concentrations are
sis is via lymph node biopsy and holds no fetal
checked 6 and 10 weeks after delivery.
or maternal risk. CT or PET studies usually used

in staging are contraindicated in pregnancy and
Other Malignancies
MRI is advised. Abdominal shielding can be used
Breast: breast cancer is the second most com-
for chest radiography. Non-Hodgkins lymphoma
monly diagnosed cancer within the reproductive
is uncommon in pregnancy however is expected
OBSTETRICS
PEER REVIEWED
JPOG MAR/APR 2015
Table 4. Treatments and Prognosis of Haematological Cancers.

Suggested Approach
Therapies
Indolent non-Hodgkin Lymphoma

All pregnancy stage
Wait and watch
2nd/3rd Trimester
Treat if symptomatic or evidence Multidrug chemotherapy

of disease progression
consider head or neck
radiotherapy for local stage
Maternal
Outcome
Fetal
Outcome
Generally
unaffected
Generally
unaffected
Generally
unaffected
Generally
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Generally
unaffected
Generally
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Aggressive non- Hodgkin Lymphoma

1st Trimester
2nd/3rd Trimester
Termination and therapy

as non-pregnant women
Treat as non-pregnant women
Multidrug chemotherapy
Asymptomatic Myeloma
All pregnancy stages
Monitor carefully
Symptomatic Myeloma
1st Trimester
2nd/3rd Trimester
Treat as non-pregnant .
But avoid lenalidomide and
thalidomide
Hodgkins Lymphoma
1st Trimester
Defer treatment to 2nd
trimester
2nd/3rd Trimester
Treat as non-pregnant
Chemotherapy
Chemotherapy
Standard therapy with multidrug Unaffected

chemotherapy
Multidrug chemotherapy. If high- Unaffected

risk consider termination and
radiotherapy
If earlier
treatment
needed, then
termination
Unaffected
Acute Myeloid Leukaemia

1st Trimester

2nd/3rd Trimester
Multidrug chemotherapy.
Consider allogenic stem cell
transplant
Unaffected
Pregnancy
termination
Probably
unaffected
Probably
unaffected
Probably
unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Unaffected
Probably
unaffected
Pregnancy
termination
Probably
unaffected
Acute Promyelocytic Leukaemia

1st Trimester
2nd/3rd Trimester

Daunorubicin with tretinoin

Daunorubicin with tretinoin
Acute Promyelocytic Leukaemia

<20 weeks
>20 weeks

65
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OBSTETRICS
JPOG MAR/APR 2015
PEER REVIEWED
Termination of Pregnancy is Recommended if Acute Leukaemia is Diagnosed in the First Trimester due to the Teratogenic Effects of
Chemotherapy.
to rise due to increase in maternal age and the
Thyroid Cancer: thyroid cancer has an incidence
growing incidence of HIV-associated lymphoma.
of 3.6 in 100,000 pregnancies. The usual pres-
Most cases of NHL are aggressive and delay
entation is with a palpable painless thyroid nod-
in treatment may lead to adverse maternal out-
ule, neck pain, hoarseness or dyspnoea. Most
comes. Local treatment with supradiaphramatic
cancers are papillary or follicular and therefore
radiotherapy in early trimesters and chemother-
well differentiated. Ultrasound, fine-needle aspira-
apy in the second and third trimester is possible
tion and chest radiography are used for diagnosis.
with no evidence of teratogenic effects.
Radioisotope scans are not advised. If well differentiated the treatment ranges from lobectomy to
Leukaemia: about 1 in 75,000-100,000 pregnan-
total thyroidectomy. Thyroidectomy can be safely
cies are complicated by leukaemia. Acute mye-
performed in the second trimester, if diagnosed
loid leukaemia accounts for two thirds of cases.
in the third trimester treatment maybe deterred till
Chronic leukaemias and Myelodysplastic syn-
delivery. Thyroxine therapy should be started im-
drome are seen mainly with increasing age and
mediately after surgery as untreated hypothyroid-
are unlikely to present in pregnancy. Acute leu-
ism may lead to higher disease recurrance and
kaemia is highly malignant but curable, therefore
have adverse effects on the cognitive function of
optimum chemotherapy regimen should be used
the fetus. Radioactive iodine as treatment should
irrespective of gestational age. Termination of
only be considered after delivery and cessation
pregnancy is recommended if Acute Leukaemia
of breast-feeding. There is no evidence that fetal
is diagnosed in the first trimester due to the tera-
outcome is adversely affected by maternal thyroid
togenic effects of chemotherapy.
cancer.
OBSTETRICS
PEER REVIEWED
JPOG MAR/APR 2015
Obstetric Monitoring in Pregnancies Where there is Co-existing Cancer Should be the Same as for High-risk Pregnancies.
Melanoma: the incidence of melanoma has been
Colorectal: colorectal cancer is a rare presenta-
progressively rising over the last forty years with a
tion with a reported incidence of approximately
third of cases developing in reproductive age. These
1 in 13,000 pregnancies. The majority of these
present with a change in, size or colour of a skin le-
are rectal carcinomas and, if confined to the
sion with possible ulceration or bleeding. Diagnosis
distal colon, a flexible sigmoidoscopy may be
is by biopsy of the skin lesion. Superficial spreading
performed. MRI is a useful tool in staging. If di-
melanoma accounts for 74% of cases followed by
agnosed at less than 20 weeks gestation then
nodular melanoma. Treatment for superficial mel-
discontinuing the pregnancy followed by surgical
anoma is achieved by local excision. For lesions
resection may be advised. After 20 weeks gesta-
less than 2 mm thickness the aim is to achieve 1 cm
tion surgery may be delayed until after delivery.
margins. With increasing depth of invasion the risk
Adjuvant chemotherapy has been shown to im-
of systemic disease increases. Sentinel node biop-
prove survival rates by 5 to 10% for stage two or
sies are advised prior to large excision with radical
three colorectal cancer.
margins. The use of interferon in pregnancy has not

been studied and should only be used post-partum.
Monitoring: obstetric monitoring in pregnancies
For advanced stage three or four disease the pla-
where there is co-existing cancer should be the
centa should be examined for metastases. If present
same as for high-risk pregnancies with regular in-
there is a 20% risk of fetal death from transplacen-
put from obstetricians. Additional fetal wellbeing ul-
tal spread. The timing of subsequent pregnancies
trasounds are recommended. Delivery should take
depends on risk of recurrence weighed against the
place in hospital with neonatal support. Where
desire for pregnancy and maternal age.
possible, delivery should be delayed until 35 to
67
68
OBSTETRICS
JPOG MAR/APR 2015
Practice Points
PEER REVIEWED
can lead to long-term emotional trauma. A diagnosis of cancer in pregnancy leads to anxiety
Cancer in pregnancy is not associated with poor neonatal and

maternal outcomes.
about the impact of cancer on this pregnancy
Incidence of cancer is rare (1:1,000) however is on the rise due to

delay in childbearing.
child or any other children into adulthood. Emo-
Cervical cancer is the most common gynaecological malignancy

in pregnancy.
provided using the expertise of a varied range
Chemotherapy as treatment is generally safe following 10 weeks

gestation.
workers.

A multidisciplinary approach is vital when constructing a
treatment plan taking into account the parents wishes along with
the best practice treatment for the malignancy.
as well as a fear of not being able to raise this

tional and psychological support needs to be
of people from medical personnel to pastoral
Pregnancy after Cancer

Fertility preservation may be an important aspect
in the life of cancer survivors. Many are fearful
that treatment may adversely affect any future offspring. Therefore, along with the implications for
37 weeks and preferably not before 32 weeks. If
the current pregnancy a discussion needs to take
preterm delivery is planned then fetal lung matura-
place regarding future pregnancies, the possi-
tion with antenatal steroids should be considered.
bility of assisted contraception, cryopreservation
Post delivery the placenta should be examined for
and the timing of future pregnancies.
metastases, but fetal spread has never been described for gynaecological cancers.
SUMMARY
An individualised action plan is crucial for cancer
Neonatal Outcome: in pregnancy with co-exist-
diagnosed in pregnancy. Surgery and chemother-
ing cancer a large portion of babies are born pre-
apy are relatively safe after the first trimester. De-
term with a high rate of admission to NICU. The
livery should be planned from 35 weeks gestation
vast majority of these deliveries, however, are ia-
onwards in an attempt to prevent the impairments
trogenically induced. The potential complications
and complications secondary to preterm delivery.
for these babies are the same as for other preterm
A multidisciplinary team approach is vital, taking
deliveries. Cytotoxic medication administered af-
into account the maternal wishes, the prognosis,
ter the first trimester of pregnancy, does not result
stage of disease and psychological well-being of
in a higher incidence of congenital malformations.
both the parent and the child.
There is limited data on long-term out comes after

in-utero exposure to chemotherapy.
Follow Up: breast-feeding during chemotherapy
is contraindicated, as most agents are excreted in
breast milk. Oncologists along with paediatricians
should arrange long-term follow up of children
exposed to chemotherapy during fetal development. Families need long-term medical and psychological support.
Psychosocial Impact
Women diagnosed with cancer experience
complex emotions, which are distressing and
Further Reading
1. Amant F, Van calsteren K, Halaska MJ, et al. Gynecologic cancers in

pregnancy: guidelines of an international consensus meeting. Int J Gynecol Cancer 2009 May;1(suppl 19):S112.
2. Amant F, Neven P, Van Calsteren K, Azim HA. Treatment of cancer
during pregnancy: the need for tailored strategies. J Clin Oncol 2010
June;28.
3. Amant F, Loibl S, Neven P, Van Calsteren K. Breast cancer in pregnancy. Lancet 2012 February;379:570579.
4. Brenner B, Avivi I, Lishner M. Haematological cancer in pregnancy. Lancet 2012 February;379:580587.
5. Greentop RCOG Guidelines, Gestational trophoblastic disease.
2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and Reproductive Medicine2014;24(11):333339.
About the Authors

Tracey A Mills is a Lecturer in Midwifery at the School of Nursing, Midwifery
and Social Work, University of Manchester, UK. Conflicts of interest: none.
Tina Lavender is Professor of Midwifery at the School of Nursing, Midwifery
and Social Work, University of Manchester, UK. Conflicts of interest: none.
Expert Opinion
INTERVIEW
Perinatal or Postnatal Dietary Interventions for Allergy

Professor Sibylle Koletzko
Head, Division of Gastroenterology and Hepatology

Department of Pediatrics
Dr. von Hauner Childrens Hospital
Ludwig-Maximilians-University of Munich, Germany
How important are food allergies

and what do we currently know
about the heritability of this group of
disorders?
Allergic diseases are common and their
incidence is increasing in many countries.
They should be recognized early as atopic
dermatitis (AD) begins within the first year
of life in 60% of patients. The German Infant
Nutritional Intervention (GINI) study showed
that infants with AD are at increased risk for
mental health problems by the age of 10
years.1,2
The heritability of allergic diseases is well
known, but a negative history of parental
allergies does not guarantee that a child
will be free from food allergies. As many
as 15% to 18% of children without a family
history of allergy still develop eczema.3-7 The
percentage of those with atopic eczema is
only about 50% among children without a
family history, but the pattern of increase in
its incidence over time is similar to that found
in children with a positive family history.6
Can you bring us up-to-date on the

tendency of these disorders for
co-morbidity?
Eczema, allergic rhinitis, and asthma often
co-exist in children. A recent analysis of
>16,000 children followed within 12 ongoing
European birth cohorts determined that comorbidity among these disorders may not
only be due to chance. Moreover, it found
that co-morbidity exists with or without
immunoglobulin E (IgE) sensitization, suggesting that these disorders share causal
mechanisms and that IgE sensitization can
no longer be considered the dominant causal
mechanism of co-morbidity.8
Can eczema be prevented by

nutritional approaches?
Yes and no. Exclusion of milk and egg from
the mothers diet during pregnancy is not
likely to substantially reduce the childs risk
of atopic diseases.9 Soy formula, avoidance
of certain solid foods, reducing the diversity
of solid food beyond 6 months of age, and
introduction of solids before 4 months of
age, are not recommended and have not
been proven to be of benefit for allergy or
food intolerance prevention.10-14 Maternal
fish, peanut, and tree nut intake during
pregnancy was found to confer protection
against asthma and allergic rhinitis, but it
must be noted that these are findings from
Table 1. Costs of treating and preventing allergic diseases25

Perspective
Denominator
Cost (Euro)
eHF-C
Cost (Euro)
eHF-W
Cost (Euro)
pHF-W
Societal
Child treated
-478
-42
-430
Case prevented
-4345
-1386
-5404
Child treated
73
110
-31
Case prevented
667
3626
-392
Health insurance
eHF-C: extensively hydrolyzed casein formula; eHF-W: extensively hydrolyzed whey formula;
pHF-W: partially hydrolyzed whey formula.
observational studies
causality is likely.15,16
and
that
reverse
An effective intervention is exclusive

breastfeeding for 4 months. It reduces the
risk of AD, at least in infancy, and may reduce
the risk for asthma, allergic rhinitis, and food
allergy.17 Another effective intervention is
the provision of partially hydrolyzed whey or
extensively hydrolyzed casein formula.18-21
For taste and cost reasons, the partially
hydrolyzed formula is the preferred choice.
Feeding these formulas within the first 4
months when the mother decides to bottle
feed has been shown to reduce the risk
for allergic diseases and atopic eczema in
infants at high risk of AD.22,23
How is cows milk protein allergy

managed?
Cows milk protein allergy (CMPA) symptoms
improve with cows milk protein (CMP)
elimination and recur with CMP challenge.24
CMP may be replaced by breast milk
provided by a mother on a CMP-free diet,
special formula in young infants, or CMP-free
complementary feeding among older infants.
Among formulas, allergenicity decreases
with increased hydrolyzation. Extensively
hydrolyzed formula for use in CMPA should
be proven to be tolerated by at least 90%
of CMP-allergic infants. Patients should
be re-evaluated every 6 to 18 months and
continued on a CMP-free diet for another 12
months after a positive reaction. Tolerance
eventually develops by 2 years and 6 years of
age in 75% and 90% of patients, respectively.
Is prevention of atopic eczema with

hydrolyzed formulas cost-effective?
The GINI trial found that hydrolyzed formulas,
including partially hydrolyzed whey formula
(pHF-W), fed with or without additional
breastfeeding for the first 4 months of life
reduced the risk of allergic diseases. Among
the 3 tested hydrolyzed formulas compared

with normal cows milk formula, pHF-W was
the most cost-saving as it decreased societal
costs (eg, lost productivity and time costs)
by 5404 euro and was shown to be costeffective as it decreased health insurance
costs by 392 euro (Table 1).25 Nutritional
intervention thus decreases the incidence
of atopic diseases and the burden they
impose in terms of cost.25,26
References: 1. Universete de Nantes. The AD Information
Server. http://adserver.sante.univ-nantes.fr/. Accessed June
2014. 2. Schmitt J, Apfelbacher C, Chen CM, et al. J Allergy Clin
Immunol 2010;125(2):404-410. 3. Kiellman. J Allergy Clin Immunol 1999. 4. Exl BM, Fritsch R. Nutrition 2001;17(7-8):642651. 5. Roduit, et al. J Allergy Clin Immunol 2012. 6. von Berg,
et al. Clin and Experimental Allergy 2009. 7. Cramer C, Link
E, Horster M, et al. J Allergy Clin Immunol 2010;125(6):12541260. 8. Pinart M, Benet M, Annesi-Maesano I, et al. Lancet
Respir Med 2014;2(2):131-140. 9. Kramer MS, Kakuma R.
Cochrane Database Syst Rev 2012;9:CD000133. 10. Osborn
DA, Sinn J. Cochrane Database Syst Rev 2006;(4):CD003741.
11. Schtzau, et al. Pediatr Allergy Immunol 2002;13:235243. 12. Filipiak B, Zutavern A, Koletzko S, et al. J Pediatr
2007;151(4):352-358. 13. Zutavern A, Brockow I, Schaaf B.
Pediatrics 2006;117(2):401-411. 14. Zutavern A, Brockow I,
Schaaf B, et al. Pediatrics 2008;121(1):e44-52. 15. Maslova
E, Strm M, Oken E, et al. Br J Nutr 2013;110(7):1313-1325.
16. Maslova E, Granstrm C, Hansen S, et al. J Allergy Clin
Immunol 2012;130(3):724-732. 17. Kramer MS. Ann Nutr
Metab 2011;59(S1):20-26. 18. Berg AV, Koletzko S, Grubl A,
Filipiak-Pittroff B, Wichmann HE, Bauer CP, et al. J Allergy
Clin Immunol 2003;111(3):533-540. 19. Berg AV, Koletzko S,
Filipiak-Pittroff B, Laubereau B, Grubl A, Wichmann HE, et
al. J Allergy Clin Immunol 2007;119(3):718-725. 20. Berg AV,
Filipiak-Pittroff B, Kramer U, Link E, Bollrath C, Brockow I, et
al. J Allergy Clin Immunol 2008;121(6):1442-1447. 21. Berg
AV, Filipiak-Pittroff B, Kramer U, Hoffmann B, Link E, Beckmann C, et al. J Allergy Clin Immunol 2013;131(6):1565-1573.
22. Alexander DD, Cabana MD. J Pediatr Gastroenterol Nutr
2010;50(4):422-430. 23. Szajewska H, Horvath A. Curr Med
Res Opin 2010;26(2):423-437. 24. Koletzko S, Niggemann B,
Arato A, et al. J Pediatr Gastroenterol Nutr 2012;55(2):221-229.
25. Mertens J, Stock S, Lngen M, et al. Pediatr Allergy Immunol 2012;23(6):597-604. 26. Ngamphaiboon, et al. J of Med
Economics 2012:1-12.
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GYNAECOLOGY
PEER REVIEWED
JPOG MAR/APR 2015
Hysterectomy for Benign

Gynaecological Disease
Sahana Gupta,
MD MRCOG;
Isaac Manyonda,
BSc PhD MRCOG
Despite the advent of newer, and in some instances less invasive, interventions for
the management of abnormal uterine bleeding, hysterectomy remains the most commonly performed major gynaecological operation. It continues to score highest in satisfaction rates. It is therefore imperative that all aspects of this operation are reviewed
on a regular basis. For example, all evidence suggests that the vaginal route is the
safest, most cost-effective approach affording rapid recovery, yet the majority of hysterectomies are still performed by the abdominal route. Newer approaches such as
robotic surgery have captured the imagination of the enthusiasts, yet this approach
is hugely expensive, and there are no data justifying its use over the laparoscopic
or indeed the conventional approach. Quality of life should remain the principal outcome measure for hysterectomy for benign disease, and therefore the impact of the
various approaches to hysterectomy should address this outcome. Complications of
any new approach should be addressed, and the question that continues to elude
an answer, namely why there are such widely and wildly varying rates of hysterectomy between surgeons in one hospital, between hospitals in one region, between
the regions and between countries, should continue to be addressed, and perhaps
one day the definitive study that will answer the question will be undertaken.
69
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GYNAECOLOGY
JPOG MAR/APR 2015
PEER REVIEWED
Hysterectomy Remains the Most Common Major Gynaecological Operation Performed Worldwide.
INTRODUCTION
dalities of treatment, particularly in the treatment
Hysterectomy remains the most common major
of dysfunctional uterine bleeding, the advantag-
gynaecological operation performed worldwide.
es must be weighed against the risks of surgery
About 600,000 hysterectomies are carried out
and the potential benefits/ advantages of other
in the US and 40,000 in England per year. Forty
alternative treatments. There is no evidence to
percent of women all over the world will have hys-
suggest that hysterectomy increases long-term
terectomy by the age of 64 and indication for the
mortality, except when concomitant oophorecto-
majority will be to relieve symptoms and improve
my is undertaken. However, few operations raise
quality of life. Since the early twentieth century,
greater passions than hysterectomy and the cur-
hysterectomy has been the definitive treatment
rent topics of debate and controversy include the
for pelvic pathology, the commonest indication
best approach for doing the operation, the widely
being fibroid disease. The majority of hysterec-
varying rates of hysterectomy, whether or not to
tomies are carried out abdominally except when
conserve the ovaries at the time of hysterecto-
utero-vaginal prolapse is the pathology at hand.
my, the impact of hysterectomy on quality of life,
Despite the advent of endometrial ablative proce-
and whether more conservative treatments such
dures, and the introduction of the levonorgestrel
as endometrial ablation, the LN-IUS and uterine
intrauterine system (LN-IUS) for menorrhagia, the
artery embolisation could be more effective and
hysterectomy rate has not declined worldwide ex-
therefore replace hysterectomy in the long run.
cept in the Scandinavian countries and recently
Resolutions to these controversies can only come
in the UK. Although hysterectomy rates highest
through robust research which are currently lack-
in satisfaction scores compared with other mo-
ing. This article will discuss some of these issues
GYNAECOLOGY
PEER REVIEWED
JPOG MAR/APR 2015
and also touch upon recent developments in the

techniques of hysterectomy, including outpatient
vaginal hysterectomy, single-port laparoscopic hysterectomy, hysterectomy via transvaginal
natural orifice transluminal endoscopic surgery
(NOTES) and robotically assisted hysterectomy.
VARIOUS ROUTES OF
HYSTERECTOMY: OUTCOMES
AND COST-EFFECTIVENESS
The three popular approaches to hysterectomy
for benign diseases are abdominal hysterectomy, vaginal hysterectomy (VH) and laparoscopic
hysterectomy. Laparoscopic hysterectomy has
three further subdivisions: laparoscopic assisted
vaginal hysterectomy (LAVH) in which a vaginal
hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation,
laparoscopic subtotal hysterectomy, and total
laparoscopic hysterectomy (TLH), where there is
no vaginal component, and the vault is sutured
laparoscopically. It is now widely believed that
vaginal hysterectomy should be a standard de-
A Cochrane Review Concluded that both Vaginal And Laparoscopic

Hysterectomies were Associated with Fewer Infections and Episodes
of Raised Temperature and Shorter Hospital Stay.
fault operation for all hysterectomies. In 2010, the

American Association of
resumed normal activity more quickly compared
Gynaecologic Laparoscopists outlined a
to when the procedure was performed by the ab-
position statement stating that most hysterec-
dominal route. Despite this, 66% of hysterecto-
tomies for benign disease should be performed
mies are abdominal, 22% vaginal and only 12%
either vaginally or laparoscopically, and that con-
laparoscopic. In a recent survey of US gynae-
tinued efforts should be taken to facilitate these
cologists, respondents were asked what kind of
approaches. Vaginal and laparoscopic hyster-
hysterectomy they would choose for themselves
ectomies are associated with low surgical risks
or their spouse. Only 8% preferred an abdominal
and involve shorter hospital stay. In comparison,
approach while most opted for either a vaginal
abdominal hysterectomy requires a relatively
or laparoscopic approach. Thus, although the
large abdominal incision and is associated with
gynaecologists recognised the benefits of a min-
increased incidence of wound infections, longer
imally invasive or vaginal approach, they do not,
hospital stay and delayed return to normal activi-
in practice, offer to their patients what they would
ty. In a review of 10 years experience of morbidity
choose for themselves. This is likely to be at least
and mortality for hysterectomies, an overall com-
in part due to lack of technical expertise and/or
plication rate of 44% for abdominal and 27.3%
confidence in performing the procedure.
for vaginal hysterectomy has been reported. A
What should the gynaecologist choose be-
Cochrane review concluded that both vaginal
tween the vaginal (VH), total laparoscopic (TLH)
and laparoscopic hysterectomies were associat-
or laparoscopic assisted vaginal hysterectomy
ed with fewer infections and episodes of raised
(LAVH)? In a recent prospective randomized
temperature, shorter hospital stay, and women
controlled trial comparing total laparoscopic to
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When Comparing LaparoscopicTotal Versus Subtotal Hysterectomy, the Former is Associated with More Short-term Complications
Whereas the Latter is Associated with More Long-term Complications.
vaginal hysterectomy, it was reported that lap-
terectomy was not cost-effective relative to vagi-
aroscopic hysterectomy was associated with
nal hysterectomy. Vaginal hysterectomy requires
7% haemorrhage, 2.5% ureteric injuries and 86
no specific additional equipment compared with
minutes operating time, whereas the respec-
laparoscopic hysterectomy, depending on the
tive figures for vaginal hysterectomy were 2.5%
type of disposable equipment used. Hence the
haemorrhage, no ureteric injuries and 46 minutes
cost of laparoscopic hysterectomy is significantly
operating time. Cochrane review found no added
higher than vaginal hysterectomy.
benefit for laparoscopic over vaginal hysterectomy.

In appropriately selected patients, evidence
SUPRACERVICAL HYSTERECTOMY/
SUBTOTAL HYSTERECTOMY
suggest that VH should be the preferred approach
Although the debate on whether subtotal hys-
over LAVH. In a report on severe complications
terectomy preserves sexual, bowel and bladder
associated with hysterectomy, studies suggest
function when compared to total hysterectomy
that LAVH was associated with the most risk of
has been largely resolved, gynaecologists are
severe complications both operatively and post-
still to be found providing inaccurate information
operatively as well as longer operating time with
to women and therefore limiting their choice. The
comparable outcomes. Clearly more good quali-
evidence will therefore be briefly presented again.
ty data is needed. The EVALUATE hysterectomy
Sexual satisfaction was reported with similar
trial with regard to cost-effectiveness, comparing
frequency before surgery and 1 year after surgery
abdominal, vaginal and laparoscopic methods of
by women in a Danish study, irrespective of the
hysterectomy concluded that laparoscopic hys-
type of hysterectomy. In a UK study, the frequen-
GYNAECOLOGY
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cy of intercourse, orgasm, and the rating of sexual
not generalisable and therefore not applicable
relationship with a partner measured before and
to the broader practice of gynaecology. A 2012
after surgery were similar for both groups. Similar
Cochrane review of randomised controlled trials
findings were obtained in a US study for sexual
concluded that robotic surgery was not associ-
function, health related quality of life, including
ated with improved effectiveness or safety. It is
sexual desire, orgasm, frequency and quality,
associated with significantly increased cost, with
and body image, measured 2 years after surgery.
some estimates suggesting that robotic surgery
A large multi-centre, double-blind trial concluded
is approximately 3,000 more expensive than lap-
that neither procedure adversely affected bladder
aroscopic hysterectomy. The robotic surgery en-
or bowel function.
thusiasts would vigorously dispute this, and time
When comparing laparoscopic total versus
and experience will tell.
subtotal hysterectomy, the former is associated
cations. The short-term complications are blood
ALTERNATIVES TO HYSTERECTOMY
AND CURRENT STAND IN THE
UNITED KINGDOM
loss, urinary tract infection, vaginal vault haemat-
The total number of procedures performed for
oma, ureteric injuries and febrile illness. The long-
menorrhagia has significantly increased between
term complications are vaginal bleeding, abdom-
2000 and 2008. This may reflect an increasing
inal wall problems, dyspareunia, post-operative
awareness among women of the availability of
pelvic pain, pelvic organ prolapse, and cervical
therapies to treat menorrhagia, but it has also
stump problems. Laparoscopic supra-cervical
been argued that the introduction of endometri-
hysterectomy also seems to be superior to lapa-
al ablation procedures has lowered the threshold
roscopic assisted vaginal hysterectomy in terms
for surgery. It has also been suggested that the
of hospital stay, blood loss and complications.
increased figures reflect a failure of the levonorg-
with more short-term complications whereas the

latter is associated with more long-term compli-
estrel intrauterine system (Mirena) to control men-
ROBOTICALLY ASSISTED
HYSTERECTOMIES
orrhagia. Endometrial ablation, especially using
The robotic surgical platform allows a surgeon to
simpler to perform with a short learning curve and
perform the procedure from a remote console.
reduced complication rates than hysterectomy.
the second generation devices, are regarded as
Potential benefits of robotic surgery include in-
At present, after failure of medical therapy
creased range of motion with instrumentation,
that includes Tranexamic acid, guidance from the
three-dimensional stereoscopic visualisation and
National Heavy Menstrual Bleeding Audit (from
improved ergonomics for the surgeon. However,
the Royal College of Obstetricians and Gynaecol-
while the robotic approach confers major advan-
ogists) and the National Institute for Health and
tages for procedures such as prostatectomy for
Clinical Excellence (NICE) guidelines on Heavy
which alternative minimal access approaches
Menstrual Bleeding is to offer the woman a levo-
are limited both the laparoscopic and vaginal ap-
norgestrel intra-uterine system or second gener-
proaches are already widely available and used
ation ablative procedures. NICE has encouraged
for removal of the uterus. Despite the rapidly
the use of ablation as a primary therapy, particu-
growing enthusiasm for robotic hysterectomy,
larly if the menorrhagia has a severe impact on
the majority of available data comes from small
quality of life. If the above treatment modalities
observational studies reported from single insti-
fail, then the woman qualifies to be counselled
tutions, with the procedures performed by highly
for hysterectomy. The RCOG and NICE recognise
experienced surgeons. Thus at present the re-
that at present most of these hysterectomies are
sults from robotic surgery for hysterectomy are
carried out abdominally, with the concomitant
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longer hospital stay, increased post-operative
The published data on UAE suggest symp-
morbidity, longer recuperation period and signif-
tomatic improvement rates of 60 to 90%, fibroids
icantly delayed return to the workplace. Ideally
shrinkage rates of up to 70% and hysterectomy
these women should be offered a vaginal hyster-
rates of 0 to 2%. Health related quality of life stud-
ectomy with all its known benefits, but the chal-
ies have also shown significant improvements.
lenge is the lack of vaginal surgical skills among
Serious infections (1 to 2%) and deaths following
gynaecologists, rendering abdominal hysterecto-
UAE compare favourably with both myomecto-
my the default operation. It is evident that a major
my and hysterectomy. While a published rand-
vaginal hysterectomy training programme is re-
omized trial has compared UAE to predominantly
quired in the UK, and the authors of the RCOG/
hysterectomy, research that compares UAE to
NICE reports go on to add that this stand should
myomectomy, both being uterus-sparing inter-
also be reflected in the postgraduate training cur-
ventions, is urgently required to provide accurate
riculum.
data to better inform the choices that women and
As mentioned earlier, fibroids are the major
their gynaecologists will have to make.
indication for hysterectomy in both the US and

ue to be the main treatment modalities and even
OVARIAN CONSERVATION
AT HYSTERECTOMY
after the advent of uterine artery embolisation not
At the time of doing hysterectomy for benign gy-
all gynaecologists or institutions in the UK offer it
naecological indications, surgeons and patients
routinely. While myomectomy results in 80% res-
are often faced with the decision of whether to per-
the UK. Hysterectomy and myomectomy contin-
Fibroids are the major indication for hysterectomy in both

the US and the UK
olution of menorrhagia symptoms, it is associated
form a concomitant prophylactic oophorectomy.
with increased blood loss, operating time, pain,
The major benefits of prophylactic oophorectomy
post operative morbidity and longer hospital stay
are the reduction in the risk of ovarian cancer and
than hysterectomy, while in 20 to 25% women,
the need for oophorectomy in future. However,
additional procedures, such as repeat myomec-
oophorectomy is associated with a number of se-
tomy or conversion to hysterectomy (although in
quelae. Among premenopausal women, it results
skilled hands the reported rate of conversion to
in an immediate surgical menopause and all of its
hysterectomy is as low as 1 to 2%) may be nec-
attendant side effects. In addition, several studies
essary. The risk of recurrence of fibroids follow-
have suggested that oophorectomy increases the
ing myomectomy is 4 to 47% and up to 98% risk
long-term risks of coronary artery disease, bone
of adhesion formation has been reported. This
fractures, neurological changes and possibly
explains why many gynaecologists offer wom-
mortality. Furthermore, the potential benefits of
en a hysterectomy rather than a myomectomy.
ovarian conservation may not be limited to pre-
However, with women increasingly postponing
menopausal women. Post-menopausal ovaries
child-bearing to their mid-thirties or later, when
continue to produce androgens that are peripher-
fibroids are more common and more symptomat-
ally converted to oestrogen. There are emerging
ic, gynaecologists will face an increasing demand
data that suggest that ovarian preservation may
for uterus-sparing interventions from women with
be beneficial even up to 65 years of age. At pres-
symptomatic fibroids.
ent, the recommendation from both the Colleges
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(UK and the US) is to undertake individualised

risk assessment based on the womans family
and personal history.
Studies suggest that the rate of ovarian conservations in women undergoing hysterectomy
for benign indications, in women younger than 50
years of age, is increasing. Changes in the rate of
hysterectomy in women 50 - 65 years of age have
been more modest, and the majority of these
women still undergo ovarian removal. A number
of patient, procedural and hospital factors are associated with oophorectomy. Women having vaginal and laparoscopic hysterectomy are less likely
to undergo oophorectomy, perhaps driven by not
only technical considerations but also the underlying indication for the procedure. In an American study, the rates of oophorectomy have been
shown to be influenced by race, insurance status
and region, with ovarian conservation being 58%
more common in Black women and in women living in eastern US and recipients of Medicaid.
COMPLICATIONS
OF HYSTERECTOMY
Although some of the issues on complications
have been touched upon during the discussion
on the advantages and disadvantages of various
There are Emerging Data that Suggest that Ovarian Preservation may
be Beneficial Even up to 65 Years of Age.
routes of hysterectomy, it is worthwhile to elaborate here as complications are obviously such
infection. Fever can be due to post-operative
an important topic.
atelectasis, a pyrogenic reaction to tissue trau-
The rate of infectious complications after
ma or formation of pelvic haematoma. A 2009
hysterectomy is variable. The most common in-
Cochrane meta-analysis found that when com-
fections include vaginal cuff cellulitis, infected
pared to total abdominal hysterectomy, subtotal,
haematoma or abscess, wound infection, urinary
vaginal and laparoscopic including laparoscop-
tract infection, respiratory infection, and febrile
ic assisted vaginal (LAVH), had lower infection
morbidity. An important principle is the distinc-
rates. There was no difference between vaginal
tion between post-operative infections and fe-
and laparoscopic hysterectomy, however com-
brile morbidity. Febrile morbidity in the postoper-
pared to LAVH, total laparoscopic hysterectomy
ative period is defined as a temperature of more
had more febrile episodes. One of the unique
than 38oC on two occasions more than 6 hours
complications is vaginal cuff cellulitis and there
apart, more than 24 hours after surgery. How-
is no difference in incidence depending on sub-
ever, the presence of a fever alone or a raised
type of hysterectomy. It is usually poly-microbial
white cell count is not an absolute confirmation
and preventive strategy include limiting surgical
of infection, and in treating infection all efforts
dead space, keeping pedicles small, avoiding
should be made to diagnose the actual site of
unnecessary subcutaneous sutures and pre-op-
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A 2009 Cochrane review found no difference

in the rate of bladder or ureteric injury based on
subtype of hysterectomy. There was also no difference between abdominal and vaginal hysterectomy. There was an increased risk of urinary tract
injury during laparoscopic hysterectomy, when
compared with abdominal or vaginal hysterectomy. The mainstay of avoiding these injuries is
proper identification of structures. In addition, if
haemorrhage is encountered in the pelvis, applying pressure in the pelvis is more prudent than
clamping and ligating, when the surgical field is
obscured. Pre-operative ureteral stenting has not
been shown to decrease the rate of ureteral injuries, however intra-operative stenting in cases
in which identification of ureters is not otherwise
possible can theoretically be useful.
Injury to the gastro-intestinal tract after hysterectomy ranges from 0.1% to 1%, with estimates
of 0.3% for abdominal and 0.2% for laparoscopic hysterectomy. The occurrence of bowel injury
with vaginal hysterectomy ranges from 0.1% to
1.0%. There was no difference in the rate of bowel
injury based on subtype or route of hysterectomy
according to a 2009 Cochrane review.
When comparing estimated blood loss based
A Cochrane Review Showed that Laparoscopic Hysterectomy had a
Significantly Lower Estimated Blood Loss than Abdominal Hysterectomy.
on the route of hysterectomy, a Cochrane review

showed that laparoscopic hysterectomy had a significantly lower estimated blood loss than abdominal hysterectomy, and vaginal hysterectomy had a
erative treatment of bacterial vaginosis and trich-
significantly lower estimated blood loss compared
omoniasis.
to laparoscopic hysterectomy. Apart from bleeding
Although venous thromboembolic complica-
from the main vascular pedicles, namely ovarian
tions after hysterectomy are common and can be
and uterine vessels, serious haemorrhage can oc-
life threatening, they are preventable events. In a
cur from the pelvic plexus of veins, which are not
Cochrane meta-analysis, there was no difference
easily isolated or dissected. The best means to
in the incidence of venous thromboembolism be-
manage bleeding from a venous plexus is direct
tween abdominal, vaginal or laparoscopic hyster-
pressure with a laparotomy pack or sponge to im-
ectomy. In recent years in the UK NICE and the
mediately control the bleeding site.
Department of Health have made the prevention
Vaginal cuff dehiscence is a postoperative
of venous thromboembolism a major priority in
complication unique to hysterectomy. Although it
all settings/health interventions, not just surgical,
is a rare complication, it can lead to serious mor-
with the performance of specific measures being
bidity. The incidence of vaginal cuff dehiscence
monitored as part of the quality assurance/perfor-
is 0.24% based on cumulative data, but appears
mance of hospitals.
to be higher (0.39%) when assessing more re-
GYNAECOLOGY
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cent years. Total laparoscopic hysterectomy
Research presents unequivocal evidence
has the highest rate of vaginal cuff dehiscence
that hysterectomy improves quality of life. Re-
(1.35%) compared with laparoscopic-assisted
search that has compared abdominal or vaginal
vaginal hysterectomy (0.28%), total abdominal
hysterectomy to endometrial ablative techniques
hysterectomy (0.15%) and vaginal hysterectomy
has found consistently higher quality of life scores
(0.08%). One estimate of cuff dehiscence after
for hysterectomy. It is not unreasonable to sup-
robotic total hysterectomy was 4.1%, based
pose that women feel better because they no
on 510 patients. A meta-analysis comparing
longer suffer from symptoms for which they had
vaginal, laparoscopic, and robotic cuff closure
to have a hysterectomy in the first place. There
found that vaginal closure has the lowest inci-
has been an ongoing debate whether new prob-
dence (0.8%), followed by laparoscopic (0.64%)
lems follow the operation. However, research
and robotic (1.64%). The increased risk seen
has not detected any difference in any dimen-
with laparoscopic-assisted routes is thought to
sions of quality of life between women who had
be attributable to the unique use of monopolar
undergone hysterectomy and women who had
electro-surgery to perform colpotomy with these
not. Studies on psychological sequelae of hyster-
modalities and possible differences in closure
ectomy, using GHQ or equivalent tools, have ar-
methods and techniques.
rived at the conclusion that, although women with

pre-operative depression are at an increased risk
QUALITY OF LIFE AND

PSYCHOLOGICAL SEQUELAE OF
HYSTERECTOMY
of deterioration in the post-operative period, in
As the vast majority of hysterectomies are per-
evidence suggests that hysterectomy improves
formed for benign indications, the fundamental
quality of life and psychological measures.
general, hysterectomy decreases psychological

symptoms. The consensus from most research
aim is not to save lives, but to improve quality

of life. Thus in clinical research quality of life is
THE VARYING HYSTERECTOMY RATES
an important outcome variable in the evaluation
There are widely varying hysterectomy rates
of any treatment modality, and its measurement
among regions, with a six fold difference amongst
prospectively and concurrently complements
developed countries with comparable resources
Vast majority of hysterectomies are performed for benign

indications, the fundamental aim is not to save lives, but
to improve quality of life
morbidity and mortality measures. As psychiatric
and as much as five fold variation within the same
symptoms can arise as a result of physical illness,
geographical area and among gynaecologists at
or might influence the manifestation and/or out-
the same hospital. In the US the lifetime risk of
come of treatment of that illness, it is also highly
hysterectomy is 25%, which compares to a much
informative to study the psychological sequelae of
lower risk of 10.4% in Denmark. There is no reason
clinical interventions. Indeed it has been argued
to suppose that women in different countries have
that the functional impact of a clinical intervention
differing incidences of menorrhagia or gynaeco-
should be the definitive arbiter of treatment suc-
logical pathologies. Then why do hysterectomy
cess, and measurement of quality of life has been
rates vary so much? There is scant research to
recommended for outcome assessment of treat-
answer this question so far. Hysterectomy is high-
ments for menorrhagia.
ly effective as a treatment modality, which might
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terectomy is a clinically highly effective intervention in terms of cure and improvement in quality
of life, its cost, with regard to both the method/
route as well as alternative treatments, has to be
considered. Cost-effectiveness analysis (CEA) is
a system that evaluates both costs and health
outcomes in order to compare healthcare programmes. Healthcare funding agencies such
as the NHS and NICE require that only direct
health related costs are included in that analysis.
The outcome of CEA is sometimes expressed
as cost-effectiveness ratio. In this ratio, all costs
(resources consumed less savings associated
with the intervention) are included in the numerator and all health outcomes (benefits less harm)
are included in the denominator. However CEA
is technically challenging and is often based on
ill-founded and misleading assumptions. It is beyond the scope of this chapter to discuss CEA in
detail, so the current received wisdom is summarised below.
Although expensive, all CEA of hysterectomy
From an Economic Point of View, the Laparoscopic Route is to be Preferred
Only when Vaginal Hysterectomy is not Possible.
demonstrate a very cost-effective and clinically

effective surgical intervention across a variety of
indications. Most alternative therapies do not treat
explain its popularity. Pharmacological treatments
the underlying cause of any of the common be-
may control but do not cure menorrhagia and
nign gynaecological pathologies and repeat treat-
may be limited by side effects, variations in com-
ment is frequently required. Removing the uterus
pliance, and the need for long term therapy. Con-
removes the site of symptom production as well
trolled trials comparing hysterectomy with endo-
as the source of the pathology. When alternative
metrial techniques have shown that hysterectomy
treatments are compared with hysterectomy, it
is more effective in permanently curing abnormal
is clear that the longer the follow up period, the
uterine bleeding and results in higher patient sat-
more cost-effective hysterectomy appears. The
isfaction scores. There is no obvious explanation
vaginal route is the most cost-effective approach.
for the regional variation, and speculation includes
The laparoscopic route has advantages in terms
gynaecologists attitudes and experience, patient
of speed of recovery and shortening of convales-
education and awareness, and availability of safe
cent intervals when compared to abdominal hys-
and effective non-hysterectomy options.
terectomy. From an economic point of view, the

laparoscopic route is to be preferred only when
HEALTH ECONOMICS
OF HYSTERECTOMY
vaginal hysterectomy is not possible. There is lit-
With the on-going economic downturn in most
to influence the decision about concomitant re-
Western countries, the need for consideration of
moval of the cervix, and almost no CEA data yet
the costs of health interventions has never been
to guide clinicians about the desirability of remov-
more acute. While it has been shown that hys-
ing the ovaries at the time of hysterectomy.
tle benefit from the cost-effectiveness perspective
GYNAECOLOGY
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INNOVATIVE APPROACHES
TO HYSTERECTOMY
Practice Points
This chapter will be concluded by writing very
Hysterectomy is the only definitive cure for DUB.
briefly about some of the innovations currently

taking place in hysterectomy techniques.
Hysterectomy rates highest in satisfaction scores compared with

other treatment modalities for DUB.
Outpatient Vaginal Hysterectomy
Hysterectomy improves quality of life, and decreases adverse

psychological sequelae.
Zakaria et al. have presented data on outpatient

vaginal hysterectomy for a 10-year period from
2000 to 2010. The approach consisted of pre
and post-operative optimisation of patients undergoing vaginal hysterectomy with the aim of
discharging them on the same day. Pre-operative
optimisation consisted of counseling on expectations about procedure and recovery, prescription
for analgesia, nausea and bowel care, emphasis
on adequate rest and presence of a post-operative care-giver. Prophylactic medication before
operation consisted of oral non-steroidal anti-inflammatory drugs (NSAIDS) and intravenous
opioids, paracervical block and local anaesthesia infiltration, transdermal anti-emetics and intravenous antibiotics 1 hour before surgery. In
the post-operative period, active management
was carried out which consisted of restoration
of normal body temperature, use of NSAIDs and
opioids for breakthrough pain, control of nausea
to allow immediate oral intake and early ambulation. Intensive post-operative surveillance was
maintained which consisted of daily phone contact and early post-operative visit if complications
were suspected.

The vast majority of hysterectomies are performed via the
abdominal route, although research suggests that the vaginal
route might be more advantageous.
Uterine fibroids are the commonest indication for hysterectomy.
It is a safe operation, with mortality rates being 0.5 to 2 per 1,000.
Some of the complications are infection, venous thromboembolism,
haemorrhage, visceral damage and vaginal cuff dehiscence. There
is no difference in urinary tract damage amongst the subtypes of
hysterectomy and between abdominal and vaginal hysterectomy,
however the risk is more in laparoscopic in comparison to both
abdominal and vaginal.

Robotic assisted vaginal hysterectomy does not confer any
significant advantage over conventional laparoscopic hysterectomy,
however it is significantly more expensive.
Conservative alternatives to hysterectomy, including endometrial
ablative techniques, the Mirena IUS, and uterine artery embolisation
for fibroids have not greatly reduced hysterectomy rates.
Hysterectomy remains the most cost-effective modality in the
treatment of menorrhagia.
Hysterectomy rates vary widely between regions, and even within
the same geographical area, the reason for which is widely
unknown.
Innovative approaches such as TSPLH and NOTES should be
viewed with cautious optimism and robust research needs to take
place before they can be introduced on a wide scale.
Preliminary results suggest that the peri-operative outcomes were similar, but when compared to in-patient vaginal hysterectomy, a cost
trocars and two 5 mm ancillary trocars. The use
saving of up to 25% was achieved. Patients older
of fewer and smaller ports has been shown to
than 65 years were more likely to stay overnight,
decrease incisional morbidity and improve cos-
which suggests that with careful patient selection
metic outcomes in laparoscopic surgery. Sin-
outpatient vaginal hysterectomy is a feasible op-
gle-port laparoscopic surgery (SPLS) has been
tion.
successfully used for nephrectomy, prostatectomy, cholecystectomy and splenectomy. In gy-
Single-port Laparoscopic
Hysterectomy (TSPLH)
naecology, it has been used for oophorectomy,
Standard laparoscopic hysterectomy has been
cystectomy, surgical treatment of ectopic preg-
performed with two 10 mm major manipulating
nancy and both total and subtotal hysterectomy.
salpingectomy, bilateral tubal ligation, ovarian
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It uses a triport access system with two flexible
Concluding Remarks
rings joined by a sleeve, and a three channel port
Although alternatives to hysterectomy for benign
for the placement of instruments ranging in size
gynaecological disease are now widely available,
from 5 to 10 mm. In a prospective randomised
including ablative techniques, the Mirena IUS and
controlled trial by
uterine artery embolisation, hysterectomy is the
Li et al. TSPLH was compared to TLH in
only definitive cure for abnormal vaginal bleeding,
terms of duration of surgery, post-operative im-
improving quality of life and rating highest in satis-
mobilisation, post-operative analgesia require-
faction scores compared with other modalities for
ment, blood loss, rate of conversion to open
treatment of dysfunctional uterine bleeding (DUB).
surgery, port site infection and hernia, duration
The vast majority of hysterectomies are performed
of hospital stay and patient satisfaction. TSPLH
via the abdominal route, despite robust research
was associated with longer duration of surgery
evidence that the vaginal approach is safer and
but shorter duration of immobilisation, lower rate
more cost-effective. In an era where the emphasis
of port site infection and higher patient satisfac-
is on the practice of evidence based medicine, this
tion than TLH.
is surprising and requires a paradigm shift in the

attitudes of gynaecologists. Questions that should
Hysterectomy via Transvaginal

Natural Orifice Transluminal
Endoscopic Surgery
be addressed include widely varying rates of hys-
The concept of natural orifice transluminal en-
and the optimal approaches to the management
doscopic surgery (NOTES), which uses the
of fibroids.
terectomy, why gynaecologists continue to perform hysterectomy through the abdominal route
natural orifices of the body as the surgical

channels for endoscopy, is a new development
in the field of minimally invasive surgery, Part
of the concept is to avoid injuries to the abdominal wall. Transvaginal NOTES combines
the technique of conventional vaginal surgery
with the newly offered laparo-endoscopic single site surgery (LESS), which not only widens
the scope of vaginal surgery but also produces a scarless abdomen. A detailed discussion
of the technique is beyond the scope of this
chapter, but suffice to say that the main disadvantage of this procedure is the restriction and
poor visualisation of the surgical field. However, in the first descriptive study looking at the
feasibility of the procedure, Su et al., conclud-
Further Reading
1. Carlson K, Miller B, Fowler F. The Maine womens health study: outcomes of hysterectomy. Br J Obstet Gynaecol 1994;83:556565.
2. Clarke-Pearson DL, Geller EJ. Complications of hysterectomy 121:654
673.
3. Guo Y, Tian X, Wang L. Laparoscopically-assisted vaginal hysterectomy vs vaginal hysterectomy: meta analysis. J Minim Invasive Gynaecol
2013;20:1521.
4. Li M, Han Y, Feng YC. Single-port laparoscopic hysterectomy versus
conventional laparoscopic hysterectomy: a prospective randomized
trial. J Int Med Res 2012;40:7018.
5. Perera HK, Ananth CV, Richards C, et al. Variation in ovarian conservation in women undergoing hysterectomy for benign indications. Obstet
Gynaecol 2013;121:71726.
6. Su H, Yen CF, Wu KY, Han CM, Lee CL. Hysterectomy via transvaginal
natural orifice transluminal endoscopic surgery (NOTES): feasibility of
an innovative approach. Taiwan J Obstetrics Gynaecol 2012;51:217
21.
7. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda IT. A comparison
of outcomes following total and subtotal hysterectomies. N Engl J Med
2002;347:131825.
8. Thakar R, Sultan AH. Hysterectomy and pelvic organ dysfunction. Best
Pract Res Clin Obstet Gynaecol 2005;19(3):40318.
9. Wright KN, Jonsdottir GM, Jorgensen S, Shah N, Einarsson JI. Costs
and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. JSLS 2012;16(4):51924.
10. Zakaria MA, Levy BS. Outpatients vaginal hysterectomy. Obstet Gynaecol 2012;120:135561.
ed that it can be performed successfully and

has the potential of overcoming the limitations
and broadening the indications for vaginal
2014 Elsevier Ltd. Initially published in Obstetrics, Gynaecology and Reproductive Medicine 2014;24(5):135-140.
hysterectomy.
The suggested reading list at the end of this
chapter provides scope for more information for
the interested reader with regard to these new approaches to hysterectomy.
About the Authors

Sahana Gupta is a Consultant Obstetrician and Gynaecologist at Northwick Park Hospital, Harrow, Middlesex, UK. Conflicts of interest: none declared. Isaac Manyonda is a Consultant Obstetrician and Gynaecologist
at St. Georges Hospital, London, UK. Conflicts of interest: none declared.
CONTINUING MEDICAL EDUCATION
JPOG MAR/APR 2015
Adolescent Menstrual
Problems
Nik Rafiza Afendi,
MBBChBAO (Ireland), MMed (O&G) USM;
Symphorosa Shing Chee Chan,
1 POINT
MBChB, FRCOG, FHKAM (O&G), FHKCOG
INTRODUCTION
Menstrual problems are the commonest
gynaecological complaint in adolescent
females.
The most common menstrual problems seen in paediatric and adolescent
gynaecology (PAG) clinic include dysmenorrhoea, heavy menstrual bleeding,
oligomenorrhoea and amenorrhoea. The
incidence of the menstrual problems seen
in PAG clinic varies between countries. In
Hong Kong, 47% presented with menorrhagia, prolonged menstruation, and
short menstrual cycles, 30% had amenorrhoea (27% secondary amenorrhoea
and 3% primary amenorrhoea) , 12% had
dysmenorrhoea, 11% had oligomenorrhoea1, in comparison to the cases seen
in PAG clinic in Australia, 43% presented
with dysmenorrhoea followed by 28%
with heavy bleeding, 20% with oligomenorrhoea and 8% with amenorrhoea.2
Normal menstruation should be described in terms of frequency, regularity,
Pain During Menstruation in Adolescence is Usually Primary Dysmenorrhoea (Functional).
duration, and volume or flow. A normal

menstrual cycle in adolescence is taken as
It is common for adolescent fe-
adolescents with late onset menarche, it
21 to 45 days, with duration of 3 to 7 days
males to have irregular cycles for the
can take 8 to 12 years after menarche for
and volume of less than 80 ml. Age of
first 2 to 3 years after menarche due to
their cycle to be ovulatory.6
menarche varies between countries. The
immaturity of the hypothalamic-pitui-
median age of menarche for girls in Hong
tary-ovarian axis. Unopposed oestrogen
DYSMENORRHOEA
Kong is 12 years and 9 months, while the
can cause unstable endometrium which
Pain during menstruation in adoles-
median age of menarche in other coun-
sheds irregularly causing heavy and pro-
cents is usually primary dysmenor-
tries are as follows: 13 years and 1 month
longed bleeding. Up to 85% of all cycles
rhoea (functional) which is the result
in Geneva, Switzerland, 13 years and 3
are anovulatory in the first year after me-
of excessive production of prostaglan-
months in Sweden, and 13 years and 6
narche. Even four years after menarche,
din and leukotrienes. It is one of the
months in urban Colombo, Sri Lanka.4
only 56% of the cycles are ovulatory.5 In
most commonly reported reasons for
81
82
JPOG MAR/APR 2015
Table 1. Table Summarising Various Causes of Menstrual Irregularity and

Primary Amenorrhoea
orrhoea is made mainly based on history

and examination. Pelvic examination is
not necessary if the patient is not sexual-
Causes of Menstrual Irregularities
Causes of Primary Amenorrhoea
1. Pregnancy
1. Uterine/vaginal
Imperforate hymen
Transverse vaginal septum
Mullerian agenesis
2. Endocrine causes
Polycystic ovarian syndrome
Thyroid dysfunction
Late onset congenital adrenal
hyperplasia
Cushings disease
Premature ovarian failure
3. Acquired conditions
Stressed related hypothalamic
dysfunction
Eating disorder
Exercised induced amenorrhoea
Medications
4. Tumours
Ovarian tumours
Adrenal tumours
Prolactinomas
2. Ovarian
Premature ovarian failure
Autoimmune ovarian failure
Galactosaemia
Fragile X syndrome
Turner syndrome
Radio/chemotherapy
Swyer syndrome
Polycystic ovarian syndrome
3. Hypothalamic causes
Weight loss
Excessive exercise
Kallmann syndrome
Idiopathic
4. Delayed puberty
Constitutional
Chronic debilitating illness
Endocrine disorders, eg. thyroid
disease
5. Pituitary
Hypopituitarism
Hyperprolactinaemia
6. Hypothalamic/ pituitary
Head injury
Cranial tumours or irradiation
ly active and the history is characteristic

of primary dysmenorrhoea.
The mainstay of treatment in this
age group is non-steroidal anti-inflammatory drugs (NSAIDS) and combined
oral contraceptive pills (COCP) or combination of NSAIDS and COCP. However, if a trial of NSAIDS and COCP is
unsuccessful, then it may warrant further
investigations such as pelvic ultrasound.
Secondary causes of dysmenorrhoea
that need to be excluded include endometriosis, pelvic inflammatory disease
and mullerian abnormality. Patients may
have didelphys uterus with obstructed
hemivagina that can give rise to dysmenorrhoea.9 Delayed management in these
cases may increase the risk of endometriosis in future.
HEAVY MENSTRUAL
BLEEDING (HMB)
Previously HMB was known as menorrhagia. The causes of HMB are dysfunctional uterine bleeding (DUB), pelvic
pathology, medical disorders and coagulation disorders.
The most common cause of DUB in
adolescents is anovulation due to immaturity of the hypothamic-pituitary-ovarian
axis but bleeding disorders need to be
considered in this age group. Compared
absenteeism from school or work.7 It
struation and relieved during the first few
with adults, it is uncommon to have an
is associated with normal ovulatory
days of menses. It improves as the ad-
underlying pathology such as uterine fi-
cycle with no pelvic pathology. It is in
olescent gets older and appears to be
broid or endometrial polyp. Other caus-
contrast to pain during menstruation
reduced after the first childbirth.8 It is de-
es of HMB that should be excluded in
experienced in adult which is usually
scribed as lower abdominal pain which
adolescents include thyroid dysfunction,
due to underlying causes such as en-
is cramping in nature and may radiate to
pregnancy related complications and iat-
dometriosis.
the back or the thigh. Associated symp-
rogenic cause such as anticoagulant.
Primary
dysmenorrhoea
usually
presents within a year after menarche. It

usually started before the onset of men-
toms include nausea, vomiting, bloating,

diarrhoea and headache.
The diagnosis of primary dysmen-
It is hard to objectively quantify

blood loss during menses in clinical
practice especially with variations of
JPOG MAR/APR 2015
pads and tampon brands available in
matologist, paediatrician and adolescent
bertal staging, body mass index and
the market. In general, use of 3 to 6 pads
gynaecologist.
sign of hirsutism. Investigations should
used per day is considered normal.3 His-
include pregnancy test, follicle stimulat-
OLIGOMENORRHOEA/
AMENORRHOEA
ing hormone (FSH), luteinising hormone
to change the pad every 1 to 2 hours,

prolonged menses more than 8 days as
Some causes of oligomenorrhoea and
thyroid function test and prolactin level.
well as evidence of anaemia would be
amenorrhoea are overlapped.
Ultrasound should be carried out to look
tory of blood clots and flooding, the need
Oligomenorrhoea is defined as
predictive of heavy menstrual flow.3,10
(LH), oestradiol level, testosterone level,
for features of polycystic ovary.
History such as symptoms of gum
menses that occur at interval more than
bleeding, nose bleeding, easy bruising
45 days. During the first few years of me-
or excessive bleeding during tooth ex-
narche, cycles may be long due to ano-
POLYCYSTIC OVARIAN
SYNDROME
traction give rise to suspicion of bleed-
vulation, but 90% of cycles will be within
Oligomenorrhoea and secondary amen-
ing disorders. Since bleeding disorders
the range of 21 to 45 days.
orrhoea is a common menstrual problem
3,14
Primary amenorrhoea is defined
presented in adolescents with PCOS.
11
haematological disorders is important.
as never had a menses by the age of
The reported incidence of PCOS in ado-
The reported prevalence of bleeding
14 years old with no development of
lescents with menstrual problem attend-
disorders in adolescents with HMB var-
secondary sexual characteristic or nev-
ing PAG clinic in Hong Kong is 16%.1
ies between 10.4% and 48%.12,13 The
er had a menses by the age of 16 with
PCOS in adults is diagnosed using
two most common bleeding disorders
development of secondary sexual char-
Rotterdam criteria 2003.15 It is defined
are Von Willebrand disease (VWD) and
acteristic. Primary amenorrhoea is most
when two of the three criteria listed be-
platelet dysfunction. Other hematologic
commonly caused by constitutional de-
low are fulfilled:
disorders associated with menorrhagia
lay or genetic or structural factors which
include Factor XI deficiency, haemophil-
will not be discussed further here.
are usually hereditary, family history of
1.
Oligomenorrhoea and/or anovulation.
ia carrier states, and rare factor deficien-
Secondary amenorrhoea is defined
cies. Initial blood testing for adolescents
as an absence of menses for 6 months.
2. Clinical (acne, hirsutism) or biochem-
suspected of bleeding disorder should
In the first year of menses, 5th centile for
ical (testosterone level and LH: FSH
include complete blood count, platelet
cycle length is 23 days and 95th centile
ratio >2:1) signs of hyperandrogen-
count, prothrombin time (PT) and acti-
is 90 days thus it is advocated that the
ism.
vated partial thromboplastic time (PTT)
adolescent to be investigated if the cycle
3. Polycystic ovarian morphology;12 or
as well as fibrinogen.
length is more than 90 days instead of
more follicles measuring 2 to 9mm
given reassurance that it is normal even
and/or ovarian volume more than
in the first year after menses.3
10ml.
Treatment principles for HMB are

as for adults. NSAIDS, tranexamic acid
and COCP are commonly used. Both
Oligomenorrhoea and secondary
tranexamic acids and COCP is also
amenorrhoea is associated with many
All other causes of hyperandrog-
used in the management of HMB in
conditions including endocrine causes
enism such as congenital adrenal hy-
adolescents with underlying bleeding
including polycystic ovarian syndrome
perplasia,
disorders. The use of NSAIDS in adoles-
(PCOS), thyroid dysfunction, late onset
androgen secreting tumours should be
cents with underlying bleeding disorder
congenital adrenal hyperplasia, Cush-
excluded before the diagnosis of PCOS
is contraindicated. In adolescents with
ings disease, tumours such as prol-
can be made.
bleeding disorders and menorrhagia,
actinomas and adrenal tumour, prema-
There is no agreed criteria in diag-
specific haemostatic therapies, such as
ture ovarian failure and pregnancy. It
nosing PCOS in adolescents. The di-
desmopressin and clotting factor con-
can also be caused by significant weight
agnosis of PCOS is challenging as it is
centrates are also used. Adolescents
loss, strenuous exercise, eating disor-
normal for the adolescents to have an
with HMB with underlying bleeding disor-
ders and severe stressors.
irregular menses the first few years after
ders should be jointly managed by hae-
Examination should include pu-
Cushings
syndrome
and
menarche. The most recent consensus
83
84
JPOG MAR/APR 2015
to facilitate an early intervention for long

term risk of PCOS. Adolescents who fulfilled the criteria should be followed up
closely.
PCOS has a long term risk of type
2 diabetes, dyslipidaemia, infertility, obesity, hypertension, endometrial hyperplasia and endometrial cancer in later life as
well as possible cardiovascular disease.
Management of PCOS include lifestyles changes and weight reduction in
obese adolescents. Regular screening
for diabetes and dyslipidaemia are required for early diagnosis and intervention.
Losing 5 to 10% of body weight in
overweight individuals can make a significant improvement in menstrual regularity and decrease the risk of developing
diabetes later in life. 21-23
Cosmetic treatment for those with
hirsutism includes chemical depilatories, waxing and destruction of the dermal papilla with various methods such
Acne is a Common Problem in Adolescents Making it Unreliable Sign of Hyperandrogenism
in this Age Group.
as LASER therapy. COCP treat both

the anovulation and the amenorrhea by
suppressing LH secretion, increasing
Rotterdam (ESHRE/ASRM) 2012 state-
limited normative data on ovarian vol-
sex hormone binding globulin (SHBG)
ment advocates that a formal diagnosis
ume in adolescent. During adolescence
and hence decreasing the levels of free
of PCOS in adolescents should not be
26% of ovaries have multicystic appear-
testosterone. By decreasing endoge-
made until 2 years after menarche.
ance thus making the diagnosis of PCOS
nous androgen production by the ovary
Acne is a common problem in ad-
even more difficult adolescence.17-20 It
COCP also help to treat both hirsutism
olescents making it an unreliable sign
has been suggested that in diagnosing
and acne. COCP also decrease the risk
of hyperandrogenism in this age group.
polycystic ovary in adolescence , ovarian
of endometrial cancer by causing regular
Progressive sign of hirsutism is a more
volume of more than 10ml should be in-
shedding of the endometrium.
reliable sign of hyperandrogenism. It is
cluded unlike in adults. Further studies
suggested that hyperandrogenemia may
are needed in determining the criteria of
be a more consistent marker for PCOS in
diagnosing PCOS adolescence. It has
PREMATURE OVARIAN
FAILURE
adolescents.16,17
been suggested that the three Rotter-
Premature ovarian failure (POF) can
dam criterias should be fulfilled.
be presented as primary or secondary
16
16
Ovarian morphology is best as-
17
16-17
sessed with transvaginal ultrasound but
Even though the criteria of diag-
amenorrhoea or oligomenorrhoea. The
in virginal adolescents it is limited to
nosing PCOS is overlapped with nor-
cause of POF is mostly idiopathic. It can
abdominal ultrasound. The use of ab-
mal physiological appearance in ado-
also be due to iatrogenic causes such as
dominal ultrasound is made even more
lescence, we should bear in mind that
previous exposure to chemotherapy/ra-
difficult in obese adolescents. There are
early diagnosis in adolescence will help
diotherapy, pelvic surgery, autoimmune
JPOG MAR/APR 2015
causes, chromosomal and genetic ab-
increasing the dose to optimized breast
acetamol, but it was unclear whether any
normalities such as Turner syndrome
development. At a later stage, cyclical
one NSAID is safer or more effective than
and Fragile X syndrome.
administration of progestogens for en-
others.
31
Side effects of NSAIDS include
High gonadotrophin levels suggest
dometrial protection is added. Hormone
diarrhoea, ingestion and gastric ulcers.
ovarian failure and it need to be repeated
replacement therapy (HRT) should be
Adolescents should be instructed to take
after 4 weeks. Persistently high level of
continued until the age of menopause.
NSAIDS with food to prevent gastric ir-
gonadotrophin confirms a diagnosis of

POF. Levels above 20 IU/L suggest absence of functioning ovarian tissue. Further investigations include karyotyping
Women with POF are at risk of osteoporosis,

cardiovascular events and depression.
and screening for autoimmune diseases.

It is important to rule out the presence of
a Y chromosome as it is associated with
Counselling regarding fertility such
ritation and drink a lot to prevent renal
significant risk of malignant change thus
as adoption or achieving pregnancy
adverse effects. Examples of NSAIDs
need to be removed. A dual-emission
through oocyte donation is invaluable.
used are Ponstan 250-500mg TDS/QID,
X-ray absorptiometry (DEXA) scan may
There is still a small chance of 5 to 10%
Naproxen 250-750mg TDS/QID and Ibu-
be considered for baseline assessment,
spontaneous conception in women with
profen 200-600mg TDS/QID.
as women with POF is at risk of osteo-
POF.
There is no study done specifically

on adolescents but NSAIDS are shown
penia.24
in women at high risk of POF. It is pro-
TREATMENT FOR MENSTRUAL

PROBLEMS
Tranexamic Acid
of NSAIDS in women with underlying
duced solely in the growing ovarian folli-
Tranexamic acid is an antifibrinolytic
bleeding disorders is contraindicated
cles thus use to predict ovarian reserve.
agent. There are no studies done specif-
due to their negative effect on platelet
AMH has the potential to predict who is
ically on adolescents but evidence from
aggregation.32
at risk of premature ovarian failure and
Cochrane database showed an associat-
25
could benefit from fertility counselling.
ed reduction of 40 to 50% of menstrual
COCP
Freeman et al found that with higher
flow in women with HMB.28 It has also
COCP is used as second-line for treat-
baseline AMH levels above 1.50 ng/ml,
been used successfully for the control of
ment of dysmenorrhoea in adolescents.
the median time to menopause was be-
menorrhagia in women with a variety of
It is safe and has added benefit as con-
tween 6.23 year to 13.01 year depending
known bleeding disorders.
Gastro-
traception to prevent unwanted teenage
on age group while Sowers et al found
intestinal symptoms commonly reported
pregnancy as well as reducing acne.
that AMH starts declining 5 years before
are nausea and diarrhoea. The usual
COCP prevents dysmenorrhoea by in-
the final menstrual period.26-27
dose given is 500 to 1000mg QID for 1
hibiting ovulation and by directly acting
to 5 days.
on endometrium causing thinning of
Anti-Mullerian
Hormone
(AMH)
has a potential role as a screening tool
Women with POF are at risk of os-
10,29,30
teoporosis, cardiovascular accident and
to reduce the menstrual blood flow by 25

to 35% in women with HMB.28 The use
endometrium thus reducing the amount
depression. The aims of hormonal ther-
NSAIDS
of prostaglandins and leukotrienes re-
apy include achieving pubertal develop-
NSAIDS are the first line of treatment for
leased by the endometrium.
ment in adolescents without develop-
dysmenorrhoea in adolescents. They re-
COCP is used to regulate the men-
ment of secondary sexual characteristic,
lieve primary dysmenorrhoea mainly by
ses and to reduce the menstrual flow.
treating oestrogen deficiency, and mini-
supressing the production of endome-
It reduces the menstrual blood flow by
mizing its long term sequelae.
trial prostaglandins thus reducing uter-
43% in women with HMB.33
In adolescents without secondary
ine cramps and hence reducing pain.
Minor side effects include nausea,
sexual characteristic, oestrogen therapy
NSAIDS are effective in relieving period
vomiting, headache and breast tender-
is started from a low dose and gradually
pain and appear to work better than par-
ness. The most serious side effect is ve-
85
86
JPOG MAR/APR 2015
nous thromboembolism. There is insuf-
with underlying systemic lupus erythema-
ficient evidence to determine the effect
tous.
The American College of Obstetricians and Gynecologists Committee on
of COC on weight.34 There are few stud-
In western countries, long-acting re-
Adolescent Health Care in 2007 con-
ies that found no evidence of increase
versible contraception is used as a meth-
cluded that available data in the litera-
in weight in adolescent COC users.35,36
od of contraception as well as to reduce
ture support the safety of IUS for most
There are no adverse effects on future
menstrual blood flow in adolescents. Its
women, including adolescent girls.41
fertility or attainment of peak bone mass
use is beneficial in severe physical or
A newer LNG releasing IUS is
in adolescents.37
mentally disable adolescent where they
available knowns as Fibroplant. It is
In western countries, long-acting reversible

contraception is used as a method of
contraception as well as to reduce menstrual
blood flow in adolescents.
flexible and frameless. It is a multicomponent system consisting of a non resorbable thread of which its proximal
end is provided with a single knot. The
FibroPlant-LNG IUS consists of a 3.5cm
long coaxial fibrous delivery system of
1.6mm in diameter, which delivers 14
Extended or continuous administra-
cannot cope with their menses causing
g/day of LNG. The fiber is fixed to the
tion of COCP without withdrawal bleed-
mental stress or for hygiene purposes. It
anchoring thread by means of a stain-
ing for 3 months can be useful in ado-
also has a role in adolescents with bleed-
less steel clip 1cm from the anchoring
lescents with bleeding disorders as well
ing disorders.29 Examples of long-acting
knot. It is anchored at the fundus of the
as adolescents with cognitive problem
reversible contraception are Levonorg-
uterus using the GyneFix insertion in-
associated with behavioural problems.38
esterel containing intrauterine contra-
strument. It has a lifespan of 5 years.42
ceptive devices, Depo-provera (DMPA)
Its use in nulliparous adolescents is lim-
and implanon.
ited.43
of the cycle (day 5 to day 26) have been
Intrauterine System (IUS)
DMPA
shown to reduce menstrual blood loss
MIRENA
polyethylene
DMPA is a long-acting progestin that is
by up to 87% in women with HMB. Oral
T-shaped frame intra uterine system
given as a single intramuscular injection
progestogens taken only in the luteal
containing levonorgestrel (LNG) which
of 150mg every 12 weeks. It has a role in
phase of the menstrual cycle have not
delivers high doses of progesterone (20
treatment of menorrhagia in adolescents
been shown to be effective in reducing
mg/day) continuously to the endome-
with bleeding disorders as well as func-
HMB. The mechanisms by which oral
trium causing endometrial atrophy. It is
tioning as a contraceptive method. 41 to
progestogens reduce menstrual blood
licensed for 5 years.
47% of women reported amenorrhoea at
Cyclical Progesterone
Cyclical progestogens taken for 21 days
39
flow are not fully understood.
33
is
small
MIRENA has minimal systemic side
1 year of use.44
Common side effects include fa-
effects. It causes irregular bleeding in the
Common side effects include ir-
tigue, weight gain, bloating, headaches,
first 6 months after insertion. Amenor-
regular bleeding for the first 6 months,
mood changes and depression.
rhoea is also common, 17% at one year
weight gain, bloating and breast ten-
Norethisterone is the most potent of
of use increasing to 60% with long-term
derness. It is thought to have an ad-
progestogens thus provides the best cy-
use. It reduces the menstrual flow by 71
verse effect on bone as it suppresses
cle control, but it is also the most andro-
to 96% in women with HMB.33
the circulating oestrogen which plays
40
genic and has side effects such as acne
It may need insertion under gener-
a key role in the attainment of bone
and hirsutism. It may deter continuing
al anaesthesia in virginal adolescence
mass. Adolescents on DMPA are at
treatment.
patients. The uterine cavity should be at
risk of suboptimal gains or loss of BMD
It is beneficial in adolescents where
least 5cm in length to accommodate the
while using DMPA. BMD is shown to
oestrogen containing preparations are
IUS and therefore uterine size should be
declines in female adolescents dur-
contraindicated such as in adolescents
assessed by ultrasound carefully.
ing the first 2 to 3 years of DMPA use,
JPOG MAR/APR 2015
but substantially or fully recovers to
inant upper arm. It releases 30 to 40 g
treatment options available to solve the
baseline values in most girls following
of etonorgestrel daily. Altered bleeding
menstrual problem of adolescents.
discontinuation of this contraceptive
patterns are common. Its use in adoles-
method.45
cents is limited.
Implant
CONCLUSION
Implanon is a single rod containing
In conclusion, menstrual problems are
68mg of etonorgestrel inserted subder-
the common gynaecological complaint in
mally in the inner aspect of the non-dom-
adolescents. However, there are effective
About the Authors
Dr Nik Rafiza Afendi is a visiting scholar in the Department of

Obstetrics & Gynaecology in the Chinese University of Hong
Kong, Hong Kong; and a clinical specialist in the Department
of Obstetrics & Gynaecology, Universiti Sains Malaysia, Malaysia. Dr Symphorosa Shing Chee Chan is a consultant in
the Department of Obstetrics & Gynaecology, Prince of Wales
Hospital; and a Clinical Associate Professor (honorary) in the
Department of Obstetrics and Gynaecology, the Chinese University of Hong Kong, Hong Kong.
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87
88
CME QUESTIONS
JPOG MAR/APR 2015
This continuing medical education service is brought to you by MIMS.

Read the article Adolescent Menstrual Problems and answer the following questions.
This JPOG article has been accredited for CME by the Hong Kong College of
Obstetricians and Gynaecologists.
CME ARTICLE
1 POINT
Adolescent Menstrual Problems

Answer True or False to the questions below.
True False
1. Dysmenorrhoea in adolescents is usually due to endometriosis.
2. Ultrasound should be done for investigation of dysmenorrhoea in adolescents on
the first visit.
3. Ponstan can be safely used in treatment of menorrhagia in adolescents with
underlying bleeding disorder.
4. History of bleeding tendency in adolescents with heavy menstrual bleeding is
important.
5. Formal diagnosis of PCOS should not be made within 2 years of menarche.
6. Premature ovarian failure is mostly due to chromosomal abnormalities.
7. There is a small chance of spontaneous conception in patient with premature
ovarian failure.
8. 15 year old girl with normal secondary sexual characteristic who had not yet
attained menarche should be investigated for primary amenorrhoea.
9. NSAIDS can reduce the menstrual blood flow by 25 to 30% in women with heavy
menstrual bleeding.
10. Levonorgestrel intrauterine device is safe to be use in adolescents.
Name in BLOCK CAPITALS: ______________________________

Signature: ______________________________________________
CME Answers
for JPOG Jan/Feb 2015
HKCOG CME Article: Semen Analysis What a

Clinician Should Know
Date: ___________________________________________________
Please mail your completed answer sheet back to:
The Secretariat
Hong Kong College of Obstetricians & Gynaecologists
Room 805, Hong Kong Academy of Medicine Jockey Club Building
99 Wong Chuk Hang Road, Aberdeen, Hong Kong
Answers
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T

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JPOG

HONG KONG ISSN 1012-8875

JOURNAL OF PAEDIATRICS, OBSTETRICS & GYNAECOLOGY

MAR/APR 2015 VOL. 41 NO. 2

HAIR LOSS IN INFANCY

JPOG MAR/APR 2015

MAR/APR 2015 VOL. 41 NO. 2

Associate Professor Department of Paediatrics and Adolescent Medicine

Board Director, Obstetrics and Gynaecology

Head, Department of Obstetrics and Gynaecology

Professor Biran Affandi

Dr Karen Kar-Loen Chan

The University of Hong Kong

The University of Hong Kong

Associate Professor Daisy Chan

Dato Dr Ravindran Jegasothy

Singapore General Hospital

Dean at the Medical Faculty,

Professor Kenneth Kwek

KK Womens and Childrens Hospital,

KK Womens and Childrens Hospital,

KK Womens and Childrens Hospital,

Adjunct Associate Professor

KK Womens and Childrens Hospital,

Associate Professor Jeffrey Low

The University of Hong Kong

National University Hospital, Singapore

Professor Carmencita D Padilla

University of the Philippines Manila

University of the Philippines Manila

Professor Seng-Hock Quak

Professor Kok Hian Tan

KK Womens and Childrens Hospital,

Kwong Wah Hospital, Hong Kong SAR

Dr Catherine Lynn Silao

Dr Ethiraj Balaji Prasath

Thomson Fertility Centre, Singapore

Associate Professor Dwiana

JPOG MAR/APR 2015

MAR/APR 2015 VOL. 41 NO. 2

Publisher Ben Yeo

Hair problems in children are not uncommon

Enquiries and Correspondence

Caroline Champagne, Paul Farrant

A diagnosis of cancer in pregnancy has

Ayshini Samarasinghe, Mahmood I Shafi

JPOG MAR/APR 2015

MAR/APR 2015 VOL. 41 NO. 2

Hysterectomy for Benign Gynaecological

Adolescent Menstrual Problems

Despite the advent of newer, and

The most common menstrual problems seen in paediatric

Sahana Gupta, Isaac Manyonda

JPOG welcomes papers in the

Comprehensive reviews providing the latest clinical information

Interesting cases seen in general practice and their management.

Vignettes of illustrated cases with clinical photographs.

JPOG MAR/APR 2015

bar four of the children had been fitted

Children with mild hearing

cy was accountable for the deaths of

Post-mortem serum vitamin D