Migration of a screw below the labia majora following internal fixation of a fracture of the pelvis.
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Female↗
Biomedical subjects
Guylaine Lefebvre
Publications and source records attributed to Guylaine Lefebvre.
Primary dysmenorrhea consensus guideline.
METHODS: Members of this consensus group were selected based on individual expertise to represent a range of practical and academic experience both in terms of location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology backgrounds. The consensus group reviewed all available evidence through the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS: This document provides a summary of up-to-date evidence regarding the diagnosis, investigations, and medical and surgical management of dysmenorrhea. The resulting recommendations may be adapted by individual health care workers when serving women who suffer from this condition. CONCLUSIONS: Dysmenorrhea is an extremely common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle, medications, and allied health services should be used to limit the impact of this condition on activities of daily living. In some circumstances, surgery is required to offer the desired relief. OUTCOMES: This guideline discusses the various options in managing dysmenorrhea. Patient information materials may be derived from these guidelines in order to educate women in terms of their options and possible risks and benefits of various treatment strategies. Women who find an acceptable management strategy for this condition may benefit from an improved quality of life.
Diagnosis, Differential↗
Prevalence of primary dysmenorrhea in Canada.
OBJECTIVE: The aim of this study was to describe the prevalence, clinical effect, characteristics, and underlying risk factors of primary dysmenorrhea (PD) in Canada. METHODS: A stratified, random sample of 2721 women 18 years and older was identified, and the women were interviewed by telephone. Data about menstrual symptoms and patterns and socio-demographic factors were obtained. The frequency, severity, and effect of menstrual pain were quantified. Logistic regression analysis was performed in order to identify independent risk factors for PD. RESULTS: In the sample, 1546 women were having menstrual periods; of these, 934 (60%) met the criteria for PD. Sixty percent of the women with PD described their pain as moderate or severe. Fifty-one percent reported that their activities had been limited, and 17% reported missing school or work because of PD. The prevalence of PD decreased with increasing age (P < 0.001) and increased with smoking (P = 0.002). Users of oral contraceptives (OCs) tended to have less pain than non-users (P = 0.005). Socio-economic status, nulliparity, and earlier age at menarche were not independently associated with PD. However, nulliparous women, smokers, and women not using OCs were more likely to report disabling symptoms. CONCLUSIONS: The majority of Canadian women will suffer from dysmenorrhea at some time during their reproductive years. Available prescription treatments are underused. Young age, smoking, and non-use of OCs are independent risk factors for PD.
Adolescent↗
The detection and management of vaginal atrophy.
OBJECTIVE: To support the practitioner in the diagnosis of vaginal atrophy and in the management of the related symptoms. OPTIONS: The modalities of evaluation range from basic pelvic examination, examination of the vulva, and laboratory tests. OUTCOMES: A comprehensive approach to the detection of vaginal atrophy and a discussion of available therapeutic and nontherapeutic options. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Diagnosis of vaginal atrophy is often a challenge because women are unwilling to report symptoms, which have the potential to significantly decrease their quality of life. Increased clinical suspicion is the first step in the diagnosis of vaginal atrophy, which will prompt the initiation of safe therapies with proven efficacy. RECOMMENDATIONS: 1. Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C) 2. Regular sexual activity should be encouraged to maintain vaginal health. (II-2B)3. Women experiencing recurrent urinary tract infections should be instructed that consumption of pure cranberry-lingonberry juice, rather than cranberry drink, will decrease their risk of urinary tract infections. (I-A) 4. Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid use of hormone replacement therapy. (I-A) 5. Women experiencing vaginal atrophy can be offered any of the following effective vaginal estrogen replacement therapies: conjugated equine estrogen cream (I-A), a sustained-release intravaginal estradiol ring (I-A), or a low-dose estradiol tablet (I-A). 6. Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C) 7. For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal estrogen therapy should be offered. (I-A).
Administration, Intravaginal↗
Hysterectomy: the right to choose.
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Canada↗
The management of uterine leiomyomas.
OBJECTIVE: The objective of this document is to serve as a guideline to the investigation and management of uterine leiomyomas. OPTIONS: The areas of clinical practice considered in formulating this guideline are assessment, medical treatments, conservative treatments of myolysis, selective artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health-care provider. OUTCOMES: Implementation of this guideline should optimize the decision-making process of women and their health-care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits. EVIDENCE: English-language articles from MEDLINE, PubMed, and the Cochrane Database were reviewed from 1992 to 2002, using the key words "leiomyoma," "fibroid," "uterine artery embolization," "uterine artery occlusion," "uterine leiomyosarcoma," and "myomectomy." The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: The majority of fibroids are asymptomatic and will not require intervention or further investigations. For the symptomatic fibroid, hysterectomy offers a definitive solution. However, it is not the preferred solution for women who wish to preserve their uterus. The predicted benefits of alternative therapies must be carefully weighed against the possible risks of these therapies. In the properly selected woman with symptomatic fibroids, the result from the selected treatment should be an improvement in the quality of life. The cost of the therapy to the health-care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat treatment modalities. RECOMMENDATIONS: 1. Medical management should be tailored to the needs of the woman presenting with uterine fibroids and geared to alleviating the symptoms. Cost and side effects of medical therapies may limit their long-term use. (III-C) 2. In women who do not wish to preserve fertility and who have been counselled regarding the alternatives and risks, hysterectomy may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-A) 3. Myomectomy is an option for women who wish to preserve their uterus, but women should be counselled regarding the risk of requiring further intervention. (II-B) 4. Hysteroscopic myomectomy should be considered as first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (I-B) 5. It is important to monitor ongoing fluid balance carefully during hysteroscopic removal of fibroids. (I-B) 6. Laparoscopic myolysis may present an alternative to myomectomy or hysterectomy for selected women with symptomatic intramural or subserous fibroids who wish to preserve their uterus but do not desire future fertility. (II-B) 7. Uterine artery occlusion may be offered as an alternative to selected women with symptomatic uterine fibroids who wish to preserve their uterus. (I-C) 8. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, and that long-term data regarding efficacy, fecundity, pregnancy outcomes, and patient satisfaction are lacking. (III-C) 9. Removal of fibroids that distort the uterine cavity may be indicated in infertile women, where no other factors have been identified, and in women about to undergo in vitro fertilization treatment. (III-C) 10. Concern of possible complications related to fibroids in pregnancy is not an indication for myomectomy, except in women who have experienced a previous pregnancy with complications related to these fibroids. (III-C) 11. Women who have fibroids detected in pregnancy may require additional fetal surveillance when the placenta is implanted over or in close proximity to hen the placenta is implanted over or in close proximity to a fibroid. (III-C) 12. In women who present with acute hemorrhage related to uterine fibroids, conservative management consisting of estrogens, hysteroscopy, or dilatation and curettage may be considered, but hysterectomy may become necessary in some cases. (III-C) 13. Hormone replacement therapy may cause myoma growth in postmenopausal women, but it does not appear to cause clinical symptoms. Postmenopausal bleeding and pain in women with fibroids should be investigated in the same way as in women without fibroids. (II-B) 14. There is currently no evidence to substantiate performing a hysterectomy for an asymptomatic leiomyoma for the sole purpose of alleviating the concern that it may be malignant. (III-C) VALIDATION: This guideline was reviewed and accepted by the Clinical Practice Gynaecology Committee, and by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SPONSOR: The Society for Obstetricians and Gynaecologists of Canada.
Adult↗
Emergency contraception.
OBJECTIVE: To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. OPTIONS: The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital copper intrauterine devices, are reviewed. OUTCOMES: Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. EVIDENCE: MEDLINE and the Cochrane Database were searched for English-language articles published from January 1998 through March 2003, to update the previous SOGC guidelines published in 2000. Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Key words used were: emergency contraception, post-coital contraception, emergency contraceptive pills, postcoital copper IUD. VALUES: The studies reviewed were classified according to criteria described by the Canadian Task Force on the Periodic Health Exam and the recommendations for practice were ranked based on this classification. BENEFITS, HARMS, AND COSTS: These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC. RECOMMENDATIONS: 1. Women who have had unprotected intercourse and wish to prevent pregnancy should be offered hormonal EC up to 5 days after intercourse. (II-2A) 2. A copper IUD can be used up to 7 days after intercourse in women who have no contraindications. (III-B) 3. Women should be advised that the levonorgestrel EC regimen is more effective and causes fewer side effects than the Yuzpe regimen. (I-A) 4. Either 1 double dose of the levonorgestrel EC regimen (1.5 mg) or the regular 2-dose levonorgestrel regimen (0.75 mg each dose) may be used, as they have similar efficacy with no difference in side effects. (I-A) 5. Hormonal EC should be started as soon as possible after unprotected sexual intercourse. (II-2B)6. Women of reproductive age should be provided with a prescription for hormonal EC in advance of need. (I-A) 7. The woman should be evaluated for pregnancy if menses have not begun within 21 days following EC treatment. (III-A) 8. A pelvic examination is not indicated for the provision of hormonal EC. (III-A) Validation: These guidelines have been reviewed by the Clinical Practice Gynaecology and Social and Sexual Issues Committees of the Society of Obstetricians and Gynaecologists of Canada. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.
Canada↗
SOGC clinical guidelines. Hysterectomy.
OBJECTIVE: To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully. OPTIONS: The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners. OUTCOMES: Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits. EVIDENCE: Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery. RECOMMENDATIONS: Benign Disease 1. Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A) 2. Abnormal uterine bleeding: Endometrial lesions must be excluded and medical alternatives should be considered as a first line of therapy. (III-B) 3. Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired. (1-B) 4. Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must include pelvic supporting procedures. (II-B) 5. Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence that hysterectomy will cure chronic pelvic pain. When the pain is confined to dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer relief. (II-C) Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A) 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B) 3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded. (I-B) Invasive Disease 1. Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (I-A) Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding. (II-B) 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-C) 3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment. (II-C) Other Indications 1. Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer. (III-C) Surgical Approach 1. The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy. (III-B) VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive. SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.
Algorithms↗