A study of the pregnancy outcome in 3320 teenagers revealed a low incidence of pre-eclampsia and anaemia and high rates of eclampsia, prematurity and low birthweight. The perinatal loss was 2.2 per cent and there was one maternal death. A comprehensive programme designed to improve antenatal surveillance is recommended for adolescents.

Forty-six cervical conizations were performed over a ten-year period for diagnostic or therapeutic purposes. Twenty-nine women were under 45 years of age. The most common reason for conization was an abnormal Papanicolaou smear. The overall incidence of neoplasia was 80.4 per cent. The high complication rate of 28.4 per cent emphasizes the need for a less traumatic technique of excisional biopsy.

A twelve-year retrospective study of 54 consecutive cases of endometrial carcinoma revealed that post-menopausal bleeding was the commonest symptom, and the major associated risk factors were obesity and hypertension. Panhysterectomy was the corner-stone of treatment while adjunctive therapy was based on certain prognostic factors and the operator's preference.

A nine-year review of 103 cases of shoulder dystocia identified obesity, diabetes mellitus and post-datism as important predisposing risk factors. There was a positive correlation with birthweight. Abnormal labour patterns were invariably absent and perinatal outcome was disastrous. The best strategy is to anticipate and avoid this obstetrical emergency.

To test the hypothesis that obesity represents a risk factor in pregnancy, we conducted a prospective case-control study to determine whether or not there was any divergence in the obstetric outcome among 132 obese women from that in a control group of 136 non-obese patients. Obese mothers had an increased incidence of pregnancy-induced hypertension and gestational diabetes but there was no significant difference in the duration of pregnancy or in the frequency of low Apgar score at 1 minute. The favourable fetal outcome in obese parturients reflects an increased awareness of the possible medical and obstetric complications and an early recourse to abdominal delivery.

A prospective randomised clinical trial comprising 510 pregnant patients was performed to determine whether supplementation with calcium, low-dose aspirin or a combination of calcium and low-dose aspirin can lower the incidence of hypertension in pregnancy. Greatest benefits were obtained with calcium. Perinatal mortality was lowest in the aspirin group.

We determined the causal pathways of pregnancy-related deaths over a 16-year period. Pregnancy-induced hypertension was the chief contributor to our high maternal mortality rate of 36.9 per 100 000 births. Anaesthetic-related deaths were due to a combination of Mendelson's syndrome and faulty intubation technique. An improvement in the health-management system to identify high-risk mothers who need intensive emergency care and the availability of experienced personnel for obstetric anaesthesia appear to be indispensable requirements for reducing and minimising adverse maternal outcome in Trinidad.

The objective of this retrospective analysis of 344 singleton pregnancies of gestational ages greater than 24 weeks conducted at a tertiary hospital was to determine the fetal outcome in relation to the mode of delivery of the fetus with a breech presentation. Caesarean section was performed in 157 mothers, and 187 babies were delivered vaginally. There was no statistical difference in the perinatal outcome for breech fetuses delivered either abdominally or vaginally. Cord prolapse and arrest of the after-coming head were responsible for five fetal losses, four of which were delivered vaginally. Neonatal morbidity comprising nerve injury, birth asphyxia and seizures occurred in 11 newborns, nine of whom were delivered vaginally. One mother sustained a massive intra-operative haemorrhage during a caesarean section which necessitated an emergency hysterectomy. We conclude that a policy of planned vaginal birth for selected breech fetuses with a low threshold to proceed to caesarean section may be in the best interests of both mother and child.

A 7-year retrospective survey was conducted in order to determine local trends in caesarean section rates, maternal outcome and indications for the procedure. The annual rate of caesarean births has not exceeded 10.0% of deliveries. The overall rate, at 7.4% for the period of study, was not significantly different from that obtained a decade and a half ago. Significant procedure-related morbidity was uncommon. In view of preventable anaesthetic maternal deaths, a plea is made for an increased use of regional in preference to general anaesthesia in selected cases.

An objective analysis of our clinical experience with the intrapartum management of twin gestations was undertaken in order to determine whether or not routine caesarean section is justified when the first twin presents by the breech. The perinatal mortality rate for breech first twins delivered vaginally was not statistically different from vertex presentations. There was no perinatal loss among babies delivered vaginally by the breech. There was no difference in perinatal outcome for the breech first twin born abdominally or vaginally. Our findings have allayed the fear that non-vertex vaginal delivery of the first or second twin is dangerous. We conclude that in the absence of a uterine scar or a footling presentation, there is no valid reason to prohibit vaginal delivery when either twin presents by the breech.

Polycystic ovary syndrome (PCOS) is associated with high levels of depression, which impact quality of life and limit self-efficacy, yet less is known about prevalence of anxiety. This cross-sectional, observational study of community-based women with PCOS comprehensively examined mood and found that anxiety existed at higher levels than depression, anxiety was underdiagnosed, and more women with PCOS who reported infertility were depressed.

Polycystic ovarian syndrome (PCOS) is the commonest endocrinopathy among women of reproductive age with an estimated prevalence of about 10%. Type 2 diabetes, cardiovascular disease, endometrial cancer, breast cancer and ovarian cancer are some of the most important emerging issues regarding syndromes influence in womens future well being. The aim of this review is to provide clear and up to date information, based on clinical evidence, in order to advise clinicians about the late consequences of the syndrome.

Aim. Differences in subclinical cardiometabolic measures were examined as a function of oral contraceptive pills (OCP) treatment duration to compare never-treated women with four OCP-treatment groups (<1, 1-5, 5-10 and >10 years). Methods. The NHANES (1999-2004) database was used to evaluate 2089 healthy, pre-menopausal women, aged 18-55 years, with or without OCP history, no other hormonal treatment or history of systemic conditions. Outcome measures included body mass, central obesity, blood pressure, glycemia, insulinemia, lipid profile and inflammation. Analyses evaluated differences in prevalence of Metabolic Syndrome (MetS), constituent MetS and other clinical risk criteria, as well as outcome magnitudes. Analyses controlled for demographic and health-related variables, and study-eligible conditions. Results. Relative to other groups, women with >10 years OCP-use, and to some extent those with 5-10 years treatment, displayed no differences in prevalence of MetS and most risk criteria. Further analysis showed that, relative to women treated for <5 years, those with more prolonged OCP treatment displayed lower body mass and fasting glycemia with higher HDL-c levels, but more elevated LDL-c and total cholesterol. Conclusions. The findings of both beneficial and detrimental subclinical cardiometabolic differences with more long-term OCP-treatment reinforces the need to monitor changes in these factors within the context of the treated patient's risk-benefit profile. However, because the magnitude of these differences was small, relative to normative ranges, it may be concluded that OCPs, as used in recent decades, are unlikely to markedly affect cardiometabolic risk.

Hirsutism, acne, alopecia, and oligo-amenorrhea are clinical expressions of hyperandrogenism, one of the most frequent endocrine disorders in women of reproductive age. Women referred to our endocrine clinics for skin symptoms of hyperandrogenism underwent a laboratory workup to evaluate hormone measurements and received antiandrogen therapy. We retrospectively analyzed the outcome of 228 consecutive patients investigated over 6 years.Patients with hirsutism had higher levels of androstenedione, dehydroepiandrosterone sulfate (DHEAS), and salivary testosterone; lower levels of sex hormone-binding globulin (SHBG); and a higher prevalence of oligo-amenorrhea than patients with alopecia, while patients with acne showed intermediate values. Hirsutism score correlated positively with androstenedione, DHEAS, and salivary testosterone, and correlated negatively with SHBG; salivary testosterone showed the highest correlation coefficient. Total testosterone was not significantly different among patients with hirsutism, alopecia, or acne, and did not significantly correlate with hirsutism score. Hirsutism and oligo-amenorrhea were the most sensitive symptoms of hyperandrogenism, and no androgenic parameter alone allowed us to identify all cases of hyperandrogenism.Patients of central European origin sought consultation with milder hirsutism scores than patients of southern European origin. There was, however, no difference in the clinical-biological correlation between these groups, arguing against differences in skin sensitivity to androgens.Polycystic ovary syndrome, defined as hyperandrogenism (hirsutism or elevated androgens) and oligo-amenorrhea, was diagnosed in 63 patients (27.6%), an underestimate compared with other reports that include systematic ovarian ultrasound studies. Neither pelvic ultrasound, used in a limited number of cases, nor the luteinizing hormone/follicle-stimulating hormone ratio helped to distinguish patients with polycystic ovary syndrome from the other diagnostic groups. These included hyperandrogenism (hirsutism or elevated androgens) and eumenorrhea (101 patients; 44.3%); normal androgens (acne or alopecia and eumenorrhea)(51 patients; 22.4%); isolated low SHBG (7 patients; 3.1%); nonclassical congenital adrenal hyperplasia (4 patients; 1.8% of total, 4.9% of patients undergoing cosyntropin stimulation tests); and ovarian tumor (2 patients; 0.9%).Ethinylestradiol and high-dose cyproterone acetate treatment lowered the hirsutism score to 53.5% of baseline at 1 year, and was also effective in treating acne and alopecia. The clinical benefit is ascribed to the peripheral antiandrogenic effect of cyproterone acetate as well as the hormone-suppressive effect of this combination. Salivary testosterone showed the most marked proportional decrease of all the androgens under treatment. Cost-effectiveness and tolerance of ethinylestradiol and high-dose cyproterone acetate compared well with other antiandrogenic drug therapies for hirsutism. The less potent therapy with spironolactone only, a peripheral antiandrogen without hormone-suppressive effect, was effective in treating isolated alopecia in patients with normal androgens.

OBJECTIVE: To verify the conclusions of the Endocrine Society Guidelines that patients with mild hirsutism and no other important clinical signs (menstrual irregularities, infertility, central obesity, acanthosis nigricans, rapid progression of the hirsutism, clitoromegaly) should not be further studied. DESIGN: Retrospective study in patients referred because of mild hirsutism and no other clinical signs. SETTING: Department of Clinical Medicine of the University of Palermo. PATIENT(S): One hundred fifty-two patients with mild hirsutism. INTERVENTION(S): Measurement of serum testosterone, dehydroepiandrosterone sulfate, 17-OH-Progesterone, assessment of ovulation by measurement of progesterone in 21 to 24 days and ovarian ultrasound. RESULT(S): In 72 (47%) patients a diagnosis of polycyctic ovarian syndrome (PCOS) was performed. Polycyctic ovarian syndrome patients included 56 patients with the mild ovulatory form (OV-PCOS) but also 16 patients with the anovulatory form (classic PCOS). Three (2%) patients had nonclassic adrenal hyperplasia. CONCLUSION(S): Because of the high prevalence of PCOS and the possibility of finding nonclassic 21-hydroxylase deficiency, patients with mild hirsutism need a diagnostic evaluation that should include 17-hydroxyprogesterone measurement plus assessment of ovulation and ovarian ultrasound.

Objective. The clinical symptoms of nonclassic adrenal hyperplasia (NCAH) are identical with polycystic ovary syndrome (PCOS). The aim of our study was to determine the prevalence of nonclassic adrenal hyperplasia (21-hydroxylase-deficiency) in hyperandrogenic women, its biochemical, endocrine and clinical characteristics and to compare them with parameters of patients with ovarian hyperandrogenism. Methods. Since 1999, 298 patients with elevation of at least one androgen and manifestation of one of the clinical androgenic symptoms (oligo/amenorrhea, hirsutism or acne) have been identified in our database. A diagnosis of NCAH was considered when the basal or stimulated 17-hydroxyprogesterone was elevated. Results. Only eight patients were identified as having 21- hydroxylase deficient NCAH in the whole group of 298 hyperandrogenic women. Hirsutism and acne were found only in three, two patients, five of them had oligo/amenorrhea. Seven patients had both elevated basal and stimulated 17-hydroxyprogesterone, while in one case only elevation of stimulated level was found. All of the NCAH patients had elevated concentrations of testosterone, six DHEA, lower SHBG was found in four patients. Surprisingly, none of the NCAH patients had increased DHEAS. Conclusion. In our study, the prevalence of NCAH in hyperandrogenic women was 2.68%. Their leading symptom was oligomenorrhea, skin androgenic disorders were a minor clinical problem. None of the NCAH patients had an elevated DHEAS, the androgen dominantly produced by the adrenal glands.

Polycystic ovary syndrome (PCOS) is a complex, multifaceted, heterogeneous disorder that affects ~5 to 10% of women of reproductive age. It is characterized by hyperandrogenism, polycystic ovaries, and chronic anovulation along with insulin resistance, hyperinsulinemia, abdominal obesity, hypertension, and dyslipidemia as frequent metabolic traits (metabolic syndrome) that culminate in serious long-term consequences such as type 2 diabetes mellitus, endometrial hyperplasia, and coronary artery disease. It is one of the most common causes of anovulatory infertility. However, the heterogeneous clinical features of PCOS may change throughout the life span, starting from adolescence to postmenopausal age, largely influenced by obesity and metabolic alterations, and the phenotype of women with PCOS is variable, depending on the ethnic background. The etiology of PCOS is yet to be elucidated; however, it is believed that in utero fetal programming may have a significant role in the development of PCOS phenotype in adult life. Though a woman may be genetically predisposed to developing PCOS, it is only the interaction of environmental factors (obesity) with the genetic factors that results in the characteristic metabolic and menstrual disturbances and the final expression of the PCOS phenotype. Irrespective of geographic locations, a rapidly increasing prevalence of polycystic ovarian insulin resistance syndrome, excess body fat, adverse body fat patterning, hypertriglyceridemia, and obesity-related disease, such as diabetes and cardiovascular disease, have been reported in Asian Indians, suggesting that primary prevention strategies should be initiated early in this ethnic group. In lieu of the epidemic increase in the prevalence of obesity and diabetes mellitus in most industrialized countries including China and India owing to Westernization, urbanization, and mechanization, and evidence suggesting a pathogenetic role of obesity in the development of PCOS and related infertility, active intervention to combat the malice of these disorders is warranted. Pharmacologic therapy is a critical step in the management of patients with metabolic syndrome when lifestyle modifications fail to achieve the therapeutic goals, and studies in China and India have proved to be effective.

Aim: To study the prevalence, reproductive hormone profiles and ovarian sonographic appearance of Thai women with polycystic ovary syndrome (PCOS). Methods: One thousand and ninety-five women were screened for oligomenorrhea/amenorrhea, and the clinical symptoms of hyperandrogenism. Ovarian morphology and volume were assessed by ultrasonography in diagnosed cases. Blood was taken for the measurement of the follicle stimulating hormone, luteinizing hormone, prolactin, testosterone, androstenedione, dehydroepiandrosterone and 17-hydroxyprogesterone. Results: The prevalence of PCOS was 5.7%. The mean age of women with PCOS was less than that of non-PCOS cases (27.4 +/- 6.5 and 31.1 +/- 6.4 years, respectively; P < 0.0001). Abnormal uterine bleeding and infertility were the leading presenting symptoms. The mean ovarian volume in women with PCO appearance was 9.22 +/- 4.36 mL compared to 6.53 +/- 3.31 mL in those without this appearance (P = 0.04). Hyperandrogenemia was confirmed in 23 of the 62 cases (37.1%). Conclusions: The prevalence and clinical presentations of Thai women with PCOS were similar to those in other reports. However, hirsutism, elevated testosterone level and acanthosis nigricans were uncommon in our population. Serum androstenedione was a more sensitive indicator of hyperandrogenemia than total testosterone. Further research is needed to clarify whether there is an ethnic difference in endocrine profiles and risks of metabolic syndrome.

The polycystic ovary syndrome is the most common endocrine disorder affecting women. It is a heterogeneous familial condition of uncertain aetiology. The diagnosis is made by the detection of polycystic ovaries on ultrasound examination and the occurrence of single or multiple clinical features such as menstrual cycle disturbances, obesity, acne, hirsutism, alopecia and biochemical abnormalities such as hypersecretion of luteinising hormone and testosterone. In a significant number of women with this condition there is impaired insulin metabolism. Women with the polycystic ovary syndrome are at an increased risk of developing diabetes and possibly cardiovascular disease in later life. The management should be symptom-orientated. Menstrual cycle regulation may be attained with the combined oral contraceptive pill or cyclical progestogen therapy. In obese women, with the loss of weight, the symptoms and endocrine profile are generally improved. Short-term treatment with metformin may be useful in women with insulin resistance. Hyperandrogenism may be treated with the contraceptive pill containing cyproterone acetate or with short-term low-dose anti-androgen therapy, together with effective contraception. Ovulation may be induced with clomiphene citrate with careful monitoring, failing which low-dose gonadotrophin therapy or laparoscopic ovarian diathermy are effective options.

Context. Oral contraceptives may worsen the metabolic profile of patients with polycystic ovary syndrome (PCOS), favoring the use of insulin sensitizers in these patients. Objective. To compare the effects on metabolic classic cardiovascular risk factors of a contraceptive pill with those of the insulin sensitizer metformin. Design. Randomized, parallel, open-label clinical trial. Setting. Academic Hospital. Patients. Thirty-four consecutive PCOS patients. Interventions. Patients were randomized to oral treatment with metformin (850 mg twice daily) or with the Diane(35) Diario (35microg of ethinyl-estradiol plus 2 mg of cyproterone acetate) pill for 24 weeks. Main outcome measures. Hyperandrogenism, lipid profiles, and indexes of glucose tolerance and insulin sensitivity at baseline and after 12 and 24 weeks of treatment. Results. Diane(35) Diario resulted in higher reductions in hirsutism score and serum androgen levels compared with metformin. Menstrual regularity was restored in all the patients treated with Diane(35) Diario compared with only 50% of those receiving metformin. Plasma Apo A-I and HDL-phospholipids levels increased with Diane(35) Diario whereas metformin did not induce any change in the lipid profile. On the contrary, the insulin sensitivity index increased with metformin but did not change with Diane(35) Diario. No differences in the frequencies of abnormalities of glucose tolerance and dyslipidemia were found between both treatments. Conclusions. Diane(35) Diario appears to be superior to metformin for the control of hyperandrogenism and for the restoration of menstrual regularity in PCOS patients, and is not associated with any clinically relevant worsening in the classic metabolic cardiovascular risk profile of these women.