Extra Information 2006

Here you will find extra information including references, links, and downloads from selected sessions of our 2006 conference.

Session 2: Contraception – new choices

Population:

Session 3: Non-invasive prenatal diagnosis from PAP smears

If you are interested in recruiting participants for this national trial on the use of pap smear for prenatal genetic diagnosis, please contact Eileen Butler on 0424 750 403 for a clinical trial pack.

If you have any questions about this research project, please feel free to discuss them with Professor Ian Findlay on (07) 3902 4620

Session 4: Chronic kidney disease in women

http://www.kidney.org.au/

Session 14 Thyroid Disease in Women

Maternal hypothyroidism and pregnancy outcome

  • 1969 Man et al, Am J Obstet Gynecol
  • 1999 Haddow et al New Engl J Med
  • 2001 Pop et al Clin Endocrinol
  • All suggest reduced neuro-psychological performance

TSH as an antenatal screening test?

  • Prevalence 1.9/1000 ie 500 women screened to detect one at risk fetus (Oats, MJA 2000)
  • Prevalence high TSH may be 2.5% in pregnancy (Klein, Clin Endocrinol 1991)
  • Hypothyroidism increases with age
  • Deferred childbearing, infertility – selective screening indicated (cvb)

Adjustment thyroxine during pregnancy

  • Minimum of every trimester
  • Some recommend every 4 weeks in first half and every 6-8 weeks in second half Aim to maintain TSH < 2.5
  • 1/4 – 1/3 require dose adjustment (depending on thyroid reserve)
  • (Le Beau, Endocrinol Metab Clin N Amer 2006)

Post partum thyroiditis

  • No history of preexisting thyroid abnormalities (excluding past post partum thyroiditis)
  • Abnormal TSH during 12/12 post partum
  • No TSH receptor antibodies and no toxic nodule

Post partum thyroiditis

  • Incidence 2-25%
  • 25% if T1DM
  • 70% if past post partum thyroiditis (Lazarus, Br J Gen Pract 1997)
  • Association with postnatal depression

Natural history post partum thyroiditis

  • Hyperthyroid phase, self limited, mild symptoms, maximum treatment is propranolol, antithyroid drugs not indicated
  • Hypothyroid phase often symptomatic, fatigue, aches and pains, often requires thyroxine which can be weaned after 12/12 except where planning another pregnancy

Post partum thyroiditis

  • Risk of permanent hypothyroidism 23-30%
  • Annual TFTs

Radionuclide scanning

  • Increased uptake with Graves (and carbimazole and propylthiouracil therapy – therefore do before treatment commenced)
  • Uptake absent in thyroiditis
  • Toxic nodule identified

Therapy for Graves Disease

  • Propylthiouracil/carbimazole
  • PTU/CMZ + thyroxine (PTU/CMZ cross placenta)
  • Ablative radioiodine (fetal thyroid destruction)
  • Surgery
  • Nothing (increased risk preterm birth)

Graves disease

  • Aim for T4 in the high section of the reference range. Lowest dose PTU
  • PTU vs CMZ controversial but PTU preferred
  • Consider antibody effect on fetus
  • Association of thyroid antibodies with miscarriage even if euthyroid
  • Often post partum exacerbation of Graves disease

Hypothyroidism and oestrogen

  • 5% of menopausal women have hypothyroidism (?screen)
  • oestrogen causes reduction in free T4 and rise in TSH in hypothyroid women (Arafah, New Engl J Med 2001)
  • Check TFTs 8-12 weeks after HT commenced

Liothyronine

  • Australian study, adequately powered showed no benefit of addition of T3 to T4. (Walsh et al, J Clin Endo Metab 2003)
  • American study showed benefit but only 33 subjects on suppressive T4 and short duration (5 weeks) (Bunevicius et al N Engl J Med 1999)
  • No evidence to suggest benefit of addition of liothyronine

Iodine deficient in 2006

  • Change in milk ingestion
  • Change in cleaning materials in dairy industry – previous iodine contamination
  • Few preparations of iodised salt
  • Lower salt intake
  • Are we iodine deficient?

Session 15 New NHMRC Guidelines for the management of Pap smear abnormalities

The new guidelines are available at:

.pdf downloads:

  1. Questions from this session (14kb)
  2. Session Slides (261kb)
  3. O&G Magazine Article (110kb)
  4. Guidelines from NHMRC (651kb)

Session 18: Parenting interventions

Triple P Website:

Session 19: Discussing sensitive issues in general practice

Session 24: Breast cancer in young women

Information on Alternative Treatments for use by health professionals:

Information for medical professionals on adjuvant therapy:

Support for women:

Support for families and children:

When parent has cancer

Fertility and Breast Cancer Project:

Session 25 Hormone Discussion

Information on the use of testosterone and DHEA in women:

Session 26 Endometriosis: a clinical enigma

What tests are appropriate prior to diagnosis?

  • Ultrasound of pelvis – only for endometrioma day 1-7
  • MRI – no definite place
  • CA125 not particularly useful
  • Laparoscopy and histological confirmation is gold standard with careful documentation of lesions, digital pictures/video and explanation to the patient.
  • (ESHRE guidelines)

Ongoing pelvic pain Adjunctive measures:

  • support in life
  • stress management
  • raise pain threshold
  • avoid menstruation
  • judicious use of analgesics
  • management of chronic pain syndrome
  • management of associated comorbidities – migraine, ibs

Medications to avoid menses

  • COC – continuously, tricycle, cyclically
  • Progestens
  • GnRH agonists (expensive, reduce bone density)
  • Place of Mirena uncertain
  • Cochrane review suggests no benefit from laparoscopic uterine nerve ablation

Useful resources

  • www.endometriosis.org
  • ESHRE guidelines
  • www.cochrane.org.au
  • Patient resource – “Endometriosis and other pelvic pain” by Dr Susan Evans

Is it genetic?

  • Australian and English families affected with endometriosis – linkage to chromosomes 10q26 and 20p13 (Treloar et al Am J Human Genet 2005)
  • Risk with affected 1st degree relative is 2 fold higher

Is surgical excision effective?

  • For pain, yes, based on one RCT of 63 women from Sutton. Cochrane review based on this.
  • For infertility, yes based on three trials, one peritoneal endometriosis and two on endometriomas.

When does she need investigation/treatment for fertility?

  • Increasing age >33 yrs
  • Severe disease e.g. bilateral large endometriomata
  • Associated factors – male factor, tubal involvement
  • Anxiety
  • Delayed conception

Role of ART in endometriosis

  • No good studies
  • Better pregnancy rates with pre treatment with GnRH agonists
  • Appropriate if tubal disease, male factor, other factors
  • IUI first if only endometriosis
  • Poor pregnancy rates compared to other causes of infertility