Jane Salodof MacNeil

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” Dr. Brown said.

“If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries, he said.

Dr. Brown estimated that 15%–20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate.

Recurrence can be up to 30% in 3 months and 80% in 9–12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709–16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant.

Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk.

All pregnant women should be screened early in pregnancy, Dr. Brown said.

For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC.

In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003: 102;527–34).

Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, according to Dr. Brown.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown.

In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and treating with the new regimen for a longer period of time.

Though randomized studies have not shown improvement with treatment of the male partner, he advocated treating the partner as well. “You may have that rare situation where it is passed back by the male,” Dr. Brown said. “I would treat the partner.”

Among other management strategies for treating recurrent BV, he listed use of condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, boric acid suppositories, and tea tree oil vaginal pessaries.

The underlying physiologic and pathologic conditions are not well understood, he said.

He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV. “We really don't understand it very well,” he said.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” Dr. Brown said.

“If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries, he said.

Dr. Brown estimated that 15%–20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate.

Recurrence can be up to 30% in 3 months and 80% in 9–12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709–16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant.

Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk.

All pregnant women should be screened early in pregnancy, Dr. Brown said.

For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC.

In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003: 102;527–34).

Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, according to Dr. Brown.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown.

In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and treating with the new regimen for a longer period of time.

Though randomized studies have not shown improvement with treatment of the male partner, he advocated treating the partner as well. “You may have that rare situation where it is passed back by the male,” Dr. Brown said. “I would treat the partner.”

Among other management strategies for treating recurrent BV, he listed use of condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, boric acid suppositories, and tea tree oil vaginal pessaries.

The underlying physiologic and pathologic conditions are not well understood, he said.

He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV. “We really don't understand it very well,” he said.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” Dr. Brown said.

“If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries, he said.

Dr. Brown estimated that 15%–20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate.

Recurrence can be up to 30% in 3 months and 80% in 9–12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709–16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant.

Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk.

All pregnant women should be screened early in pregnancy, Dr. Brown said.

For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC.

In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003: 102;527–34).

Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, according to Dr. Brown.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown.

In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and treating with the new regimen for a longer period of time.

Though randomized studies have not shown improvement with treatment of the male partner, he advocated treating the partner as well. “You may have that rare situation where it is passed back by the male,” Dr. Brown said. “I would treat the partner.”

Among other management strategies for treating recurrent BV, he listed use of condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, boric acid suppositories, and tea tree oil vaginal pessaries.

The underlying physiologic and pathologic conditions are not well understood, he said.

He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV. “We really don't understand it very well,” he said.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200.

About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts.

Dr. Zephyrin speculated that the patients receiving HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year.

Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that while 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

The clinic has 20 primary care physicians and six midlevel practitioners, according to Dr. Zephyrin. The staff was qualified to do Pap tests but often did not have the proper equipment and, therefore, referred patients to a gynecology clinic, she said.

“You can't do the Pap test unless you have the stirrups and the speculum and a chaperone. The provider may be willing and able to do it, but cannot do it because of the system variables that are in place,” she said.

“It becomes very challenging when you have to refer these women to other areas to get care. Because there is so much going on in their lives, making delivery of care as simple as possible will really allow them to get the screening they need,” Dr. Zephyrin said.

She also questioned whether the guideline should be stratified to reduce the first year screening requirement from two tests to one for women with normal CD4 counts.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200.

About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts.

Dr. Zephyrin speculated that the patients receiving HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year.

Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that while 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

The clinic has 20 primary care physicians and six midlevel practitioners, according to Dr. Zephyrin. The staff was qualified to do Pap tests but often did not have the proper equipment and, therefore, referred patients to a gynecology clinic, she said.

“You can't do the Pap test unless you have the stirrups and the speculum and a chaperone. The provider may be willing and able to do it, but cannot do it because of the system variables that are in place,” she said.

“It becomes very challenging when you have to refer these women to other areas to get care. Because there is so much going on in their lives, making delivery of care as simple as possible will really allow them to get the screening they need,” Dr. Zephyrin said.

She also questioned whether the guideline should be stratified to reduce the first year screening requirement from two tests to one for women with normal CD4 counts.

LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.

Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.

“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.

Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.

“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.

Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.

One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200.

About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).

The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.

In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts.

Dr. Zephyrin speculated that the patients receiving HAART were in the clinic more often and might have been more compliant.

Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year.

Similarly, intravenous drug users were 32% less likely than were those who were not users.

Dr. Zephyrin reported that while 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.

The clinic has 20 primary care physicians and six midlevel practitioners, according to Dr. Zephyrin. The staff was qualified to do Pap tests but often did not have the proper equipment and, therefore, referred patients to a gynecology clinic, she said.

“You can't do the Pap test unless you have the stirrups and the speculum and a chaperone. The provider may be willing and able to do it, but cannot do it because of the system variables that are in place,” she said.

“It becomes very challenging when you have to refer these women to other areas to get care. Because there is so much going on in their lives, making delivery of care as simple as possible will really allow them to get the screening they need,” Dr. Zephyrin said.

She also questioned whether the guideline should be stratified to reduce the first year screening requirement from two tests to one for women with normal CD4 counts.

SANTA FE, N.M. — One hundred thirty-five years after Pantaleoni performed the first hysteroscopy, Stephen M. Cohen, M.D., urged physicians to move the diagnostic procedure from the operating room to the office.

New technology makes office hysteroscopy more effective, less expensive, safer, and easier to perform than invasive diagnostic alternatives, according to Dr. Cohen, chief of the division of gynecology and director of women's minimal access surgery at Albany (N.Y.) Medical College. Fertility investigations and some simple surgical procedures can be done in the office with hysteroscopy, he said at a conference on gynecologic surgery sponsored by Omnia Education.

“I think all of us in the next 5 years will be doing hysteroscopic sterilizations in the office,” Dr. Cohen said, citing avoidance of intraabdominal complications and general anesthesia with hysteroscopy. “The laparoscopic sterilization will be a procedure of the past or used in very selected cases.”

Office hysteroscopy is especially useful for direct diagnosis of the cause of abnormal uterine bleeding, according to Dr. Cohen, who has served on the speakers' bureau for Karl Storz, which manufactures hysteroscopes.

“So many patients have submucous fibroids,” he said. “You can put the scope in and see those. … You can see endometrial polyps and take them out if you like.”

Dr. Cohen described the basic equipment for office hysteroscopy as relatively simple—a scope, a light source, a camera, and a monitor. He said they could be purchased separately or in a compact combination unit for about $15,000. Auxiliary instruments would include scissors, biopsy forceps, and graspers.

If the physician is concerned about doing enough procedures to cover the expense, Dr. Cohen suggested renting a unit for one or two afternoons a month when office hysteroscopies are scheduled. “If you have it in your office, you are going to use it much more,” he said.

Newer scopes allow the physician to see the entire uterus upon entering the cervix, according to Dr. Cohen. He cited the 3.5-mm Bettocchi scope as giving a “crystal clear view” and the Versascope for being disposable. Some physicians prefer flexible scopes, but they are somewhat more expensive and not absolutely necessary for office hysteroscopy, Dr. Cohen said.

Physicians also may want a printer so they can record exactly what they saw in the patient's chart. “It's also good if you get lots of patient referrals,” Dr. Cohen said. “You send printouts back to the referring physician.”

Dr. Cohen said he does office hysteroscopy entirely with local anesthesia, which is reimbursed by insurance companies and allows patients to watch in real time on the television screen.

The only painful part, Dr. Cohen said, comes at the end of the procedure when he uses a Pipelle to biopsy tissue. He saves this for last so as not to disturb the endometrium, which he also can measure during hysteroscopy.

SANTA FE, N.M. — One hundred thirty-five years after Pantaleoni performed the first hysteroscopy, Stephen M. Cohen, M.D., urged physicians to move the diagnostic procedure from the operating room to the office.

New technology makes office hysteroscopy more effective, less expensive, safer, and easier to perform than invasive diagnostic alternatives, according to Dr. Cohen, chief of the division of gynecology and director of women's minimal access surgery at Albany (N.Y.) Medical College. Fertility investigations and some simple surgical procedures can be done in the office with hysteroscopy, he said at a conference on gynecologic surgery sponsored by Omnia Education.

“I think all of us in the next 5 years will be doing hysteroscopic sterilizations in the office,” Dr. Cohen said, citing avoidance of intraabdominal complications and general anesthesia with hysteroscopy. “The laparoscopic sterilization will be a procedure of the past or used in very selected cases.”

Office hysteroscopy is especially useful for direct diagnosis of the cause of abnormal uterine bleeding, according to Dr. Cohen, who has served on the speakers' bureau for Karl Storz, which manufactures hysteroscopes.

“So many patients have submucous fibroids,” he said. “You can put the scope in and see those. … You can see endometrial polyps and take them out if you like.”

Dr. Cohen described the basic equipment for office hysteroscopy as relatively simple—a scope, a light source, a camera, and a monitor. He said they could be purchased separately or in a compact combination unit for about $15,000. Auxiliary instruments would include scissors, biopsy forceps, and graspers.

If the physician is concerned about doing enough procedures to cover the expense, Dr. Cohen suggested renting a unit for one or two afternoons a month when office hysteroscopies are scheduled. “If you have it in your office, you are going to use it much more,” he said.

Newer scopes allow the physician to see the entire uterus upon entering the cervix, according to Dr. Cohen. He cited the 3.5-mm Bettocchi scope as giving a “crystal clear view” and the Versascope for being disposable. Some physicians prefer flexible scopes, but they are somewhat more expensive and not absolutely necessary for office hysteroscopy, Dr. Cohen said.

Physicians also may want a printer so they can record exactly what they saw in the patient's chart. “It's also good if you get lots of patient referrals,” Dr. Cohen said. “You send printouts back to the referring physician.”

Dr. Cohen said he does office hysteroscopy entirely with local anesthesia, which is reimbursed by insurance companies and allows patients to watch in real time on the television screen.

The only painful part, Dr. Cohen said, comes at the end of the procedure when he uses a Pipelle to biopsy tissue. He saves this for last so as not to disturb the endometrium, which he also can measure during hysteroscopy.

SANTA FE, N.M. — One hundred thirty-five years after Pantaleoni performed the first hysteroscopy, Stephen M. Cohen, M.D., urged physicians to move the diagnostic procedure from the operating room to the office.

New technology makes office hysteroscopy more effective, less expensive, safer, and easier to perform than invasive diagnostic alternatives, according to Dr. Cohen, chief of the division of gynecology and director of women's minimal access surgery at Albany (N.Y.) Medical College. Fertility investigations and some simple surgical procedures can be done in the office with hysteroscopy, he said at a conference on gynecologic surgery sponsored by Omnia Education.

“I think all of us in the next 5 years will be doing hysteroscopic sterilizations in the office,” Dr. Cohen said, citing avoidance of intraabdominal complications and general anesthesia with hysteroscopy. “The laparoscopic sterilization will be a procedure of the past or used in very selected cases.”

Office hysteroscopy is especially useful for direct diagnosis of the cause of abnormal uterine bleeding, according to Dr. Cohen, who has served on the speakers' bureau for Karl Storz, which manufactures hysteroscopes.

“So many patients have submucous fibroids,” he said. “You can put the scope in and see those. … You can see endometrial polyps and take them out if you like.”

Dr. Cohen described the basic equipment for office hysteroscopy as relatively simple—a scope, a light source, a camera, and a monitor. He said they could be purchased separately or in a compact combination unit for about $15,000. Auxiliary instruments would include scissors, biopsy forceps, and graspers.

If the physician is concerned about doing enough procedures to cover the expense, Dr. Cohen suggested renting a unit for one or two afternoons a month when office hysteroscopies are scheduled. “If you have it in your office, you are going to use it much more,” he said.

Newer scopes allow the physician to see the entire uterus upon entering the cervix, according to Dr. Cohen. He cited the 3.5-mm Bettocchi scope as giving a “crystal clear view” and the Versascope for being disposable. Some physicians prefer flexible scopes, but they are somewhat more expensive and not absolutely necessary for office hysteroscopy, Dr. Cohen said.

Physicians also may want a printer so they can record exactly what they saw in the patient's chart. “It's also good if you get lots of patient referrals,” Dr. Cohen said. “You send printouts back to the referring physician.”

Dr. Cohen said he does office hysteroscopy entirely with local anesthesia, which is reimbursed by insurance companies and allows patients to watch in real time on the television screen.

The only painful part, Dr. Cohen said, comes at the end of the procedure when he uses a Pipelle to biopsy tissue. He saves this for last so as not to disturb the endometrium, which he also can measure during hysteroscopy.

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovarian syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said during the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovarian syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OCP) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OCP; the other 24 patients received only OCP.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCPs for at least 3 months before enrollment. Organon Inc. supplied the OCP Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OCP/simvastatin group. By contrast, in the OCP-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OCP/simvastatin patients and 28% in the OCP-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OCP/simvastatin group vs. 9% in the OCP-alone cohort.

FSH declined 8%, which was not significant, in the OCP/simvastatin patients, but it increased 21% in those taking just OCPs.

The LH:FSH ratio declined significantly in the OCP/simvastatin group (44%) and fell by 12% in the OCP-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with simvastatin/OCP vs. 8% higher with OCP alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the simvastatin/OCP patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OCP-only patients but were not much changed in simvastatin/OCP patients.

Increases in HDL cholesterol levels were similar: 9% with simvastatin/OCP and 13% with OCP alone. Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the simvastatin/OCP arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk, which Dr. Duleba said is increasingly a patient concern.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk. “In the long term, I hope to show clinical end points,” he said.

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovarian syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said during the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovarian syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OCP) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OCP; the other 24 patients received only OCP.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCPs for at least 3 months before enrollment. Organon Inc. supplied the OCP Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OCP/simvastatin group. By contrast, in the OCP-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OCP/simvastatin patients and 28% in the OCP-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OCP/simvastatin group vs. 9% in the OCP-alone cohort.

FSH declined 8%, which was not significant, in the OCP/simvastatin patients, but it increased 21% in those taking just OCPs.

The LH:FSH ratio declined significantly in the OCP/simvastatin group (44%) and fell by 12% in the OCP-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with simvastatin/OCP vs. 8% higher with OCP alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the simvastatin/OCP patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OCP-only patients but were not much changed in simvastatin/OCP patients.

Increases in HDL cholesterol levels were similar: 9% with simvastatin/OCP and 13% with OCP alone. Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the simvastatin/OCP arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk, which Dr. Duleba said is increasingly a patient concern.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk. “In the long term, I hope to show clinical end points,” he said.

LOS ANGELES — Simvastatin lowered testosterone levels by 41%, normalized gonadotropin levels, and reduced cardiovascular risk factors in a small, randomized, controlled trial, suggesting that statins may be a potential treatment for polycystic ovarian syndrome.

“Statins would improve the metabolic profile in those patients in terms of lipid levels as well as improve the hormonal problems,” study investigator Antoni J. Duleba, M.D., said during the annual meeting of the Society for Gynecologic Investigation.

The study is the first to demonstrate these benefits in women with polycystic ovarian syndrome (PCOS). Dyslipidemia is common with PCOS, but statins are almost never used in PCOS, because the patients are typically young women trying to get pregnant or are at risk of getting pregnant. Statins are contraindicated in pregnancy, said Dr. Duleba of Yale University, New Haven.

The study eliminated pregnancy as a consideration by placing all 48 study participants on oral contraceptive pills (OCP) containing 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. One 24-patient cohort was treated with 20 mg of simvastatin daily, along with OCP; the other 24 patients received only OCP.

Investigators from Yale and Poznan University of Medical Sciences in Poland are conducting the ongoing trial in that country. The women are about 23 years old on average. None received any hormonal treatment or OCPs for at least 3 months before enrollment. Organon Inc. supplied the OCP Marvelon, and Polfa, a Polish pharmaceutical company, provided simvastatin.

A comparison of hormonal levels at baseline and 12 weeks showed total testosterone fell significantly—an average of 34.6 ng/dL (41%) in the OCP/simvastatin group. By contrast, in the OCP-alone group, levels fell by only 10.9 ng/dL (14%).

Average dehydroepiandrosterone sulfate (DHEA-S) fell 26% in the OCP/simvastatin patients and 28% in the OCP-alone group. Luteinizing hormone (LH), however, was reduced 43% in the OCP/simvastatin group vs. 9% in the OCP-alone cohort.

FSH declined 8%, which was not significant, in the OCP/simvastatin patients, but it increased 21% in those taking just OCPs.

The LH:FSH ratio declined significantly in the OCP/simvastatin group (44%) and fell by 12% in the OCP-alone group—not a statistically significant decline.

As expected, the simvastatin group had a significantly improved metabolic profile: Total cholesterol was 10% lower with simvastatin/OCP vs. 8% higher with OCP alone. Low-density lipoprotein (LDL) cholesterol dropped a significant 24% in the simvastatin/OCP patients, but stayed the same in the control group. Conversely, triglyceride levels increased 21% in the OCP-only patients but were not much changed in simvastatin/OCP patients.

Increases in HDL cholesterol levels were similar: 9% with simvastatin/OCP and 13% with OCP alone. Neither group had a significant improvement in insulin sensitivity or change in body mass index.

Dr. Duleba reported that hyperandrogenia declined dramatically in the simvastatin/OCP arm, but he said 3 months is too early to determine whether this will lead to improvements in excessive hair growth or other clinical conditions associated with PCOS.

The trial employs a crossover design by which the groups have since switched regimens. The investigators also are looking at biochemical markers of endothelial function and cardiovascular risk, which Dr. Duleba said is increasingly a patient concern.

“We used to only see women who wanted to get pregnant and, on occasion, because of complaints of hirsutism,” he said. “Now, with greater understanding of cardiovascular risk factors, people come to the office and say, 'What can we do to protect ourselves from heart disease, diabetes, high blood pressure—all the cardiovascular problems that our mothers, aunts, and grandmothers had?'”

Although he would not recommend statins to women trying to get pregnant, he concluded that statins could eventually prove to be the answer to their question about cardiovascular risk. “In the long term, I hope to show clinical end points,” he said.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.