Editorial| Volume 137, ISSUE 1, P1-2, March 2008

Editors’ highlights

Published:February 18, 2008DOI:
      For doctors, the ability to move between countries is one of the attractions of a career in medicine. Patients too are now becoming more mobile. Intercontinental air travel means that obstetricians may see women who have had their early antenatal care thousands of miles away. Humanitarian crises, particularly in Africa, are bringing asylum-seekers to Europe and presenting the medical services with new challenges. Within Europe, economic migration from East to West has increased markedly in recent years and clinicians face increasing problems in communicating with patients.
      In the United Kingdom (UK) these trends have been highlighted by data in “Saving Mothers’ Lives”, the seventh report of the UK Confidential Enquiry into Maternal Deaths, published recently. Between 1995 and 2005 the total number of UK births – almost 650,000 per year – hardly changed but there was a fall of 55,000 in births to UK-born women. This was balanced by an increase in births to women from Africa, South Asia and the European Union (EU). The number from non-EU European countries trebled, to 7500. Migration is a risk factor in pregnancy, and the need for interpreters is putting another strain on overstretched maternity services. Obstetricians across Europe need to be aware of such social trends and need to argue for resources to deal with the risks these changes bring to women and babies.
      What's new? This month's review focuses on genetic counselling in Hungary but its conclusions will strike a chord in many countries. Toth and colleagues (page 3) from Szeged discuss the expectations that women have from reproductive genetic counselling, and also provide some original data. The authors conducted a questionnaire study of 181 women attending a genetic counselling clinic in Szeged and found that a large proportion of the 170 who responded wanted not only detailed information but also psychological support and shared decision-making. From these data and their own experience, the authors argue that a non-directive approach to counselling is no longer appropriate, and that counsellors need to acquire the skills to practise interpretative counselling. These insights into the complex role of the counsellor are welcome and important and we invite correspondence on this topic.
      Under the heading “European view” is a report on how women from different European countries view sexuality around the menopause. On page 10 Nappi and Nijland, from Italy and The Netherlands, report a telephone survey of 1805 women aged between 50 and 60. Most women (71%) believe it is important to maintain an active sex life but 35% reported a reduced sex drive. The incidence of sexual and other menopausal symptoms was highest in the UK and lowest in Switzerland, and sexual satisfaction was lowest among Italian women. The use of hormone replacement therapy (HRT) to treat reduced sex drive was highest in the UK and lowest in The Netherlands. The authors comment that menopausal changes are important across Europe but perception of sexuality, and the need for treatment, are influenced by cultural values and health beliefs.
      Obstetrics and maternal–fetal medicine: Violence against women is now recognised as an important issue in obstetric care and one which affects all countries. In Belgium, Roelens and colleagues from Ghent (page 37) gave questionnaires to 1362 women attending the antenatal service and received 537 responses. The lifetime prevalence of physical or sexual Intimate Partner Violence (IPV) was estimated at 10.1% and the prevalence during or immediately before pregnancy was 3.4%. Only 19.2% and 6.6% of victims of physical or sexual abuse respectively had sought medical care, and the authors found that directly asking about IPV is largely acceptable to women. In Peru, Sanchez and colleagues from Lima (page 50) conducted a case–control study using personal interviews of patients in hospital. They compared 339 women with pre-eclampsia and 337 normotensive controls and found that the prevalence of IPV was 43.1% among pre-eclamptic women and 24.3% among controls. In their study, IPV included emotional abuse and this, without physical violence, was associated with a 3.2-fold increase in the risk of pre-eclampsia.
      Obesity and morbid obesity are becoming an important problem for obstetricians in the UK and North America. There is a feeling among obstetricians that pregnancy outcome may be worse among morbidly obese women than among those with a lesser degree of obesity but data are lacking. On page 21 Yogev and Lander from New York, USA, report a cohort study of 4380 women with gestational diabetes mellitus (GDM), among whom the rates of obesity (Body Mass Index >30) and morbid obesity (BMI >35) were 15.7% and 11.6% respectively. Comparing the 760 obese women and the 559 morbidly obese women, the authors found no differences either in demographic data or in pregnancy outcome. Insulin treatment enhanced perinatal outcome, particularly in the morbidly obese patients with GDM but the authors conclude that outcome was compromised in both groups regardless of the level of obesity or treatment modality.
      Reproductive medicine and endocrinology: Vulvar Lichen Sclerosus (LS) has been linked with abnormalities of testosterone metabolism such as reduced 5-alpha reductase activity. Clinicians sometimes diagnose LS in young women taking the oral contraceptive pill (OCP). On page 56 Guenthert and colleagues from Goettingen, Germany, report a retrospective case–control study of 40 premenopausal patients with LS and 100 matched healthy women. All the women with LS were taking the OCP compared with 66% of the controls. OCPs with anti-androgenic activity were used by 70% of the LS patients and by 48% of the OCP-users in the control group. A variety of topical treatments had been used in this retrospective survey but all patients had either stopped the OCP (43%) or changed to a formulation containing a progestin without anti-androgenic activity. The authors suggest offering alternative contraception in such cases prior to topical treatment.
      Gynaecology and gynaecological oncology: Cervical cancer is the theme of several papers in this issue. In Sweden, which has had a national cervical screening programme for over 40 years, the incidence of cervical cancer has fallen but approximately 500 new cases still occur every year. Is this due to shortcomings in the programme? Lindqvist and colleagues from Malmø (page 77) analysed the screening histories of 130 women below the age of 61 diagnosed with invasive cervical cancer between 1991 and 2000. They found that 19% had experienced suboptimal handling by the screening programme but 54% of the women with cervical cancer had either not participated in the programme at all or were suboptimal participants. The authors calculate that 9.5% of women are non-participants in the programme, and these women are at an 11-fold increased risk of cervical cancer. The greatest reduction in the disease would be achieved by bringing this subgroup into the programme.
      There has been much interest in the role of male sexual partners in the epidemiology of cervical cancer and its causative agent, Human Papilloma Virus (HPV). There are recommendations that the male partners of HPV-infected women should be examined, but identification of HPV in men is difficult and investigation of aceto-white areas by peniscopy has very low specificity. On page 88 Giraldo and colleagues from Sao Paolo, Brazil, report a study of 54 asymptomatic male partners of women with low-grade squamous epithelial lesions associated with high-risk HPV. Penile scrapings were tested using a second-generation hybrid capture technique for HPV-DNA and 14 men (25.9%) were found to have high-risk HPV present. The authors suggest that this method could reduce the number of unnecessary penile biopsies and help identify men at risk of penile intra-epithelial neoplasia.
      Vaccination against cervical cancer is moving rapidly from theory to practice. Medical advances linked with sexuality and reproduction often meet with controversy and outright opposition but this varies from country to country. In the Netherlands, Lenselink and colleagues from Nijmegen (page 103) interviewed 356 parents of children aged 10–12 years and found that 88% would accept HPV vaccination for their children. Interestingly, less than a third of the parents had heard of HPV and only 14% were aware of its causal relationship with cancer. Parents’ acceptance of HPV vaccine was related to their acceptance of vaccination in general. Parents in the USA are more worried that HPV vaccination will lead to early sexual activity but those in the Netherlands do not share this concern. It seems that they trust medical researchers and official recommendations, and we must continue to take great care to ensure that this trust is justified.
      Gynaecological urology: Prolapse has always been a symptom that women mention with reluctance. In the UK, it was only after Queen Victoria died that she was found to have a procidentia. She had had nine children between 1840 and 1857. Now that family size has diminished a fall in the incidence might be expected but the lifetime risk of prolapse or incontinence is still around 11%. Vault prolapse is particularly difficult to treat. On page 108 Sentilhes and colleagues from Rouen, France, report a 97% success rate for infracoccygeal sacropexy with posterior mesh interposition in 72 patients with a mean age of 65. The main complication was vaginal erosion, which occurred in 13.9% of cases and was usually diagnosed within 6 months of operation. The rate of erosion was reduced to 5.7% by using monofilament polypropylene mesh. The median follow-up in this study was 26.3 months and the authors comment that long-term follow-up is required to confirm these results.