Background: The status of ovarian reserve markers during hormonal contraception (HC) remains uncertain with conflicting literature data. The purpose of this study was to assess the impact of HC on circulating anti-Müllerian hormone (AMH) and other ovarian reserve markers. Materials and Methods: A systematic review was conducted, including all cohort, cross-sectional, and randomized controlled studies assessing serum anti Müllerian hormone concentration in women using HC. Data sources included MEDLINE, EMBASE, DynaMed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov, and the Cochrane Library from January 2000 to October 2018. Results: A total of 366 studies were identified, of which 15 were eligible, including 3280 women, mostly using combined HC (CHC). Articles were divided according to duration of HC into short- (2-3 weeks), medium- (2-6 months), long- (>1 year), and varied-term studies. Two study designs were identified, including studies comparing AMH before and during/after CHC and studies comparing CHC users versus nonusers. Short- and medium-term studies (n = 284) reported no change in circulating AMH in women using cyclical CHC for one to six cycles. Apart from one study, all long- and varied-term studies (six studies, n = 1601) consistently showed a marked decline in AMH, antral follicle count, and ovarian volume. Three long-term studies (n = 1324) provided evidence of AMH recovery after discontinuation of HC. Conclusion: Circulating AMH seems to remain unchanged in women using cyclical CHC for up to 6 months, but appears to markedly decline in long-term users with recovery after discontinuation.

OBJECTIVE: To evaluate whether vaginoscopy or standard hysteroscopy was more successful in the outpatient setting. DESIGN: Randomised controlled multicentre trial. SETTING: Outpatient hysteroscopy clinics at two UK hospitals. POPULATION: 1597 women aged 16 or older undergoing an outpatient hysteroscopy. METHODS: Women were allocated to vaginoscopy or standard hysteroscopy using third party randomisation stratified by menopausal status with no blinding of participants or clinicians. MAIN OUTCOME MEASURES: The primary outcome was 'success', a composite endpoint defined as: a complete procedure, no complications, a level of pain acceptable to the patient, and no sign of genitourinary tract infection 2 weeks after the procedure. RESULTS: Vaginoscopy was significantly more successful than standard hysteroscopy [647/726 (89%) versus 621/734 (85%), respectively; relative risk (RR) 1.05, 95% CI 1.01-1.10; P = 0.01]. The median time taken to complete vaginoscopy was 2 minutes compared with 3 minutes for standard hysteroscopy (P < 0.001). The mean pain score was 42.7 for vaginoscopy, which was significantly less than standard hysteroscopy 46.4 (P = 0.02). Operative complications occurred in five women receiving vaginoscopy and 19 women receiving standard hysteroscopy (RR 0.26, 95% CI 0.10-0.69). CONCLUSIONS: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be considered the technique of choice for outpatient hysteroscopy. TWEETABLE ABSTRACT: Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy.

BACKGROUND: Most causes of postcoital bleeding (PCB) are benign but the most important cause is cervical cancer so it is important to refer women with postcoital bleeding for colposcopy. We evaluated women referred with postcoital bleeding for the prevalence of cervical abnormalities. METHOD(S): This was a retrospective study of 270 women referred with postcoital bleeding to the colposcopy clinic at the Royal Derby Hospital, Derby and those with suspected cervical abnormalities underwent colposcopy-directed cervical biopsies with or without treatment. RESULT S: Eighty-nine out of 124 women (72%) above 35 years and 108 out of 146 women (74%) below 35 years were seen for colposcopy within 4 weeks of referral. Final diagnoses confirmed cervical intraepithelial neoplasia in 35 women (13%) and high-grade cervical intraepithelial neoplasia in 10 women (3.7%). None of the women had cervical cancer and all had recently negative cervical smears. CONCLUSION(S): Although cervical cancer was not detected in the women referred for colposcopy, PCB stills presents a risk of coexisting cervical intraepithelial neoplasia so women should be referred for further assessment promptly within appropriate, improved waiting times. Most cases however will be benign with a high chance of symptom resolution providing reassurance.

BACKGROUND: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety. OBJECTIVE: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anaesthesia for pain control during perineal repair after vaginal delivery. DATA SOURCES: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma. METHODS OF STUDY SELECTION: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anaesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies. DATA EXTRACTION: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I2) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, fixed effect meta-analysis was used when there was no significant heterogeneity. RESULTS: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = 0.13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = 0.42). Regarding patient satisfaction, overall analysis of three studies showed significant results favouring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = 0.0005). The pooled analysis of the outcome "duration of repair" showed significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anaesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = 0.001). CONCLUSIONS: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.

Lymphoedema-distichiasis is an inherited autosomal dominant disorder of the lymphatic system. Rarely, it is associated with fetal hydrops; the risk and severity of which increases with successive generations. The causative gene is a member of the forkhead transcription factor family (FOXC2). We describe a fetus presenting with early-onset, rapidly progressing body wall oedema, bilateral pleural effusions and a pericardial effusion in a mother with known FOXC2 mutation. First trimester chorionic villus sampling confirmed FOXC2 mutation in the fetus when there was only a large nuchal translucency. As the phenotype progressed, the couple consented to in utero ultrasound-guided insertion of sequential bilateral pleuro-amniotic chest drains (at 23 weeks) which successfully drained the pleural effusions. The fetus was delivered at 39 weeks gestation by elective caesarean section in good condition. The shunts were removed postnatally, and the baby was discharged after 7 days. This is the first case described of a fetus with severe early-onset fetal hydrops secondary to FOXC2 mutation successfully treated by the prenatal insertion of bilateral pleuro-amniotic shunts.

OBJECTIVES: To establish the positive predictive values of pre-operative identification with CT imaging of metastatic diaphragm disease in surgically managed cases of advanced ovarian cancer (AOC). Additionally, we have assessed the post-operative morbidity and survival following diaphragmatic surgical intervention in a large regional cancer centre in the United Kingdom. STUDY DESIGN: A retrospective review of all cases of AOC with metastatic diaphragm disease surgically treated at the Pan-Birmingham Gynaecological Cancer Centre, UK between 1st August 2007 and 29th February 2016. RESULTS: A total of 536 women underwent surgery for primary AOC. Diaphragm disease was evident intra-operatively in 215/536 (40.1%) and 85/536 women (15.9%) underwent a procedure involving their diaphragm. Of these 85 cases, 38 peritoneal strippings (38/85, 44.7%), 31 partial diaphragmatic resections (31/85, 35.6%) and 16 electro-surgical ablations (16/85, 18.9%) were performed. There were no significant differences in post-operative complications between the three different diaphragmatic surgical groups. Of those patients who underwent peritoneal stripping or partial diaphragm resection, 12% were upstaged to stage 4A by virtue of pleural invasion. The positive predictive value for pre-operative radiological identification of diaphragmatic disease was 78.6%. CT imaging failed to detect diaphragmatic involvement despite obvious diaphragm disease during surgery in 29.4% of cases, giving a low negative predictive value of 64.8%. The sensitivity and specificity for CT imaging in detecting diaphragm disease was 44.3% and 93.8%, respectively. CONCLUSIONS: Diaphragmatic disease is often discovered in AOC. However, pre-operative assessment with CT imaging is not reliable in accurately detecting diaphragm involvement. Therefore, all patients with AOC should be regarded as in potential need for diaphragm surgery and their operation undertaken in cancer centres with adequate expertise in upper abdominal surgery. If there is a suspicion of diaphragm muscle invasion during diaphragmatic peritonectomy, the muscle should be partially resected. This will lead to potential upstaging of disease to stage 4A and therefore, to suitability for targeted therapy. In our Centre, the surgical removal of diaphragmatic disease did not significantly increase surgical morbidity.

The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

OBJECTIVES: To assess the impact of 5 or more cycles of neoadjuvant chemotherapy (NACT) and cytoreductive outcomes on overall survival (OS) in patients undergoing interval debulking surgery (IDS) for advanced ovarian cancer. METHODS: A retrospective review of patients receiving NACT followed by IDS between 2007 and 2017. Patients were analysed according to number of NACT cycles received: group 1 consisted of patients receiving ≤4 cycles and group 2 consisted of those receiving ≥5 cycles. Outcomes were stratified by cytoreductive outcome, surgical complexity, stage and chemotherapy exposure. RESULTS: 231 patients in group 1 and 167 in group 2 were identified. In group 1, the OS for those achieving Complete (R0), Optimal<1 cm (R1) and Suboptimal (R2) was 51.1, 36.1, and 34.3 months respectively. Statistically significant differences in survival were seen in patients achieving R0vR2 (p < 0.019) but not in R0vR1 (p = 0.125) or R1vR2 (p = 0.358). In group 2, the OS for those achieving R0, R1 and R2 was 53.0, 24.7, and 22.1 months respectively. Statistically significant differences were seen between R0vR1 and R0vR2 (p < 0.00001) but not between R1vR2 (p = 0.917). No difference in OS was seen between groups 1 and 2. In patients achieving R1, there was a trend towards decreasing OS with increasing exposure to NACT from 36.1 (95%CI 32.0-40.2)months with 3 cycles to 24.3 (95%CI 14.4-34.2)months with ≥6 cycles. CONCLUSIONS: Surgery with utilisation of cytoreductive procedures to achieve complete clearance should be offered to all patients even after ≥5 cycles if R0 can be achieved. R1 cytoreduction has questionable value in those receiving ≤4 cycles and no value in those receiving ≥5 cycles.

Background At 8 weeks into her third IVF pregnancy, a 40-yearold doctor presented to the Royal Derby Hospital with dyspnoea. Her breathing had worsened since the drainage of 5 litres of ascites from ovarian hyperstimulation syndrome 3 weeks prior. Her symptoms deteriorated and she was intermittently hospitalised from 28 weeks, as she was unable to sit upright without desaturating to 75% in air. This presentation was consistent with Platypnea-Orthodeoxia Syndrome (shortness of breath and arterial desaturation when upright which improves when supine). Investigations including chest X-ray, VQ scan, CTPA, Spirometry, Echo and ECG were normal. Bubble echo was initially normal, but when repeated 2 weeks later it demonstrated a right to left shunt consistent with a patent foramen ovale (PFO). She underwent a caesarean section at 35 weeks following which her symptoms resolved entirely. Objectives To establish the incidence of PFO in women of reproductive age, presenting symptoms, diagnostic tests and options for management. Methods Review of recent literature via a web based search. Results Patent Foramen Ovale is known to affect up to 1 in 3 adults based on autopsy findings from around 1000 'normal' hearts. The incidence in those aged under 30 years is 34.3%, falling to 25.4% in the over 40s. Size is known to increase with age. PFO affects men and women equally, with no difference in size between genders. It has long been recognised as a cause of unexplained stroke, particularly in those under 55, where the incidence is thought to rise to 56%. The vast majority of adults are asymptomatic, although it is occasionally associated with clinical syndromes including decompression syndrome in scuba divers, migraine (particularly with aura) and rarely with Platypnea-orthodeoxia syndrome. The diagnosis is made via Echocardiography, with trans-oesophageal echo considered the gold standard. In the UK use of 'bubble echo' has improved detection, as saline contrast is injected into a peripheral vein during the valsalva manoeuvre, following which bubbles can be seen crossing the septum. Management options include secondary prevention of paradoxical embolic stroke with anticoagulation, and percutaneous transcatheter closure. This method has now been developed for use in the second trimester to allow closure with minimal fetal radiation exposure. Conclusion Patent foramen ovale is a relatively common phenomenon in women of childbearing age and should therefore feature in the differential diagnosis of worsening shortness of breath in pregnancy, especially if positional