Editorial| Volume 130, ISSUE 1, P1-3, January 2007

Editors’ highlights

Published:November 26, 2006DOI:
      At the start of a new year it is hard to resist the temptation to look backward and forward, like the Italian deity Janus who gave his name to January. In 2007 this Journal will be 36 years old. It was conceived by the Societies of Obstetrics and Gynaecology of the Netherlands and Northern Belgium and its first editorial in 1971 invited contributions from further field. This month we have papers from a dozen countries, half of them outside Europe, and our founders – some of whom are still active in research – must be delighted with this success. Many other anniversaries are being celebrated in 2007. For example, it is exactly 500 years since the name “America” was coined by the German cartographer Martin Waldseemueller, working in France, and it is 60 years since India gained independence from the British. The Finnish composer and patriot, Jean Sibelius, died fifty years ago and on a more homely level, 2007 marks the 50th anniversary of the Xerox photocopier.
      In our own specialty, the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) will celebrate its 50th anniversary with a congress in Tokyo in September and we would also like to draw attention to a younger group, ten years old this year. In only a decade the World Health Organisation (WHO) Reproductive Health Library (RHL) has become the most established evidence-based reference work in reproductive health. With its slogan “out of libraries and into practice”, the RHL reviews clinical practices and classifies them in a spectrum of effectiveness from harmful to beneficial. Access is free in low and low-middle income countries. Its website,, gives details of the group's tenth anniversary meeting, to be held in April 2007 in Khon Kaen University in North-East Thailand. Development of this poor part of Thailand has been encouraged by the monarch, King Bhumibol—who, incidentally, celebrated his sixtieth anniversary on the throne recently.What's New?Reviews: Evidence-based recommendations are now published by all leading journals and our first review this month includes such recommendations for treatment of the premenstrual syndrome (PMS). Campagne and Campagne from Madrid (page 4) differentiate between PMS, which includes physical symptoms, and Premenstrual Dysphoric Disorder (PMDD), which is restricted to mood symptoms. The authors point out that recommendations of authoritative bodies regarding treatment are only partly supported by good evidence: there is a conflict between the idea that treatment should begin with the least complex option, and the idea that treatment should be evidence based. Their list of effective evidence-based treatments includes plant extracts such as vitex castus and St. John's Wort. In view of the number of women affected by PMS it is surprising that these have not been researched more intensively.
      Campagne and Campagne describe their “Premenstrual Profile” for assessing symptoms and our second review also discusses the assessment of a condition that causes distress to many women—urinary incontinence. Dr Ku from Seoul (page 18) comments that several disease-specific quality of life instruments have been developed to assess the effect of urinary incontinence on patients’ lives, but the variety of instruments makes it difficult for clinicians to compare the results of different studies, whose conclusions may even be contradictory. The author examines a generic instrument, the Medical Outcomes Study Short Form-36, but concludes that its scales have poor content validity for urinary incontinence and limited sensitivity to small changes in symptoms. Disease-specific instruments may be more useful than their generic counterparts but generic factors need to be evaluated in future studies and we hope that the urogynaecologists will reach agreement on a single appropriate instrument for assessment.Expert Opinion: In last month's “Editors’ Highlights” we outlined the remarkable story of vaccination against cervical cancer. In this issue Kaufmann and Schneider of Berlin give us an in-depth discussion of that research and the problems of implementing a programme which could prevent about 200,000 deaths worldwide. They point to the success of vaccination programmes against childhood infections and polio, and the complete eradication of smallpox, but they acknowledge the ethical, religious, cultural and social issues involved in immunising 9–15 year olds against a sexually transmitted virus. They call for the involvement of politicians as well as doctors in conveying information to parents and the public, and they ask the relevant authorities to produce consensus statements, recommendations and guidelines. We are mindful of the limitations that we discussed last month but we share these authors’ hope that the introduction of this vaccine will be widely supported.Obstetrics and Maternal-Fetal Medicine: It has been known for years that cervical ripening is an active process and that cervical dilatation is not just the passive result of uterine contractions pushing on the presenting part. Cervical hyaluronic acid (HA) increases during ripening and is then degraded into low molecular weight HA at the onset of labour. Past researchers have investigated the use of intracervical injection of hyaluronidase to shorten labour, and on page 46 Spallici and colleagues from Sao Paolo, Brazil, report its use in a double-blind randomised controlled trial on 168 women with an unfavourable cervix at term. The primary outcome was an improvement in the Bishop's Score to >5. The active injection had success rates of 55% and 96% at 48 and 96 h, compared to 7% and 22%, respectively with placebo. There was also a reduction in the duration of labour and an increase in the vaginal delivery rate (including cases of previous caesarean section). This method appears effective and safe, but its place in relation to other methods of cervical ripening remains to be explored.
      Perinatal mortality and maternal mortality are important indicators of reproductive health worldwide, though accurate data are not available in some developing countries. In developed countries the pattern of improvement in these rates over the years has tended to be initially rapid and then to slow down. On page 42 Scioscia and colleagues from Bari report national trends in perinatal mortality in Italy over a 50-year period. The authors focus on the role of ultrasonographic prenatal diagnosis since 1980, when termination of pregnancy became legal in Italy. They report that the proportion of infant mortality due to congenital abnormalities has remained steady at about 23% and does not seem to have been affected by the change in the law. We were interested to see that Italy's stillbirth rate fell from 30.9 in 1950 to just over 3 in 2000. In England and Wales the stillbirth rate in 2000 was 5.35 and the leading cause was intrauterine hypoxia leading to fetal death before labour. It would be interesting to know why the rate of death from this cause seems to be so much lower in Italy.Reproductive Medicine and Endocrinology: Those of us who teach reproductive endocrinology to medical students enjoy explaining the classical interaction of ovarian and pituitary hormones, which reminds us of well-designed clockwork. Our ideas of how Follicle-Stimulating Hormone (FSH) and Luteinising Hormone (LH) work have become fixed and they have been applied in clinical practice with exogenous hormone preparations. It may come as a surprise, then, to read the paper on page 99 by Gomes and colleagues from Ribeirao Preto, Brazil, who conclude that in the late follicular phase of the cycle, follicle growth can be achieved equally well with LH as with FSH, which turns out to be necessary only at the very start of the cycle. Perhaps we shall reserve this information for only the smartest medical students.
      The effects of Hormone Replacement Therapy (HRT) on cerebrovascular disease risk are controversial, with some studies reporting a protective effect, others indicating that HRT may increase the risk and others reporting no effect. Animal studies have suggested that oestrogen promotes cerebral vasodilatation, possibly by increasing the synthesis of nitric oxide. As concern has grown about the safety of exogenous oestrogen there has been increasing interest in phytoestrogens but their effects on cerebrovascular reactivity have not been investigated until now. On page 84 Lund and colleagues from Denmark report the effect of oestrogen and phytoestrogen on rabbit cerebral arteries studied in vitro. Neither treatment improved endothelial function or the expression of endothelial nitric oxide synthase. The authors concede that they may have used an inappropriate animal model but nevertheless their study does not support the theory that soy supplements can benefit cerebrovascular function.Gynaecology, Gynaecological Oncology and Urology: There are wide variations in abortion law across Europe. In France the law was changed in 2001 to allow abortion to be carried out on a minor without notifying her parents. The definition of a “minor” also varies between different countries and in France it means a woman aged under 18. Venditelli and Pons from France (page 107) compared patients seeking elective abortion before and after the new law was passed. Before 2001 16% refused to inform a parent and after 2001 the proportion increased to 38%. The reasons given for refusal did not change, however, the main one being conflict with the parents. The new law requires post-abortion interviews to be offered to patients but in practice more than 30% fail to keep their appointment. This report highlights the difficulty of providing care to young women at this vulnerable stage of their lives and the problems of applying well-meaning legislation in practice.
      Endometriosis is a troublesome condition, which often recurs after treatment, and surgery for endometriosis can itself cause problems. Medical treatment in the form of ultrasound-guided drainage and cytotoxic injection of endometriotic cysts has recently been reported. On page 129 Agostini and colleagues from Marseille, France, describe the use of methotrexate injection for treating recurrent endometriotic cysts. They followed up 14 patients for a mean of 20 months (range 13–29 months). Four patients had further recurrences, two of which were asymptomatic and were not treated. Two patients who had painful recurrences underwent repeat drainage and methotrexate injection. The authors recommend this as a simple and effective alternative to surgical treatment.
      Follow-up arrangements for cancer patients are often based on traditional practice rather than evidence. Patients and doctors alike have the feeling that there must be benefit in continuing surveillance but evidence to support this is scanty. Currently there are debates about who should undertake follow-up of cancer patients – specialist or general practitioner? – as well as about whether follow-up is worthwhile at all. On page 114 Van Wijk and colleagues from the Netherlands report a retrospective review of patients with recurrent endometrial cancer. Among 64 patients who suffered a recurrence, 34 presented with symptoms, 27 had the recurrence detected at routine follow-up (“screen detected”) and 2 had it detected by chance during bowel surgery. The 5-year survival rate for screen detected recurrence was 62% compared to 47% for the others, and the authors conclude that all patients should be thoroughly followed up irrespective of stage of primary disease.