Editorial| Volume 139, ISSUE 1, P1-2, July 2008

Editors’ highlights

      July is the month when most people look forward to holidays but it is a stressful time for medical students facing important examinations. Assessing clinical skills has never been easy and methods of doing so have changed. In the past students were watched examining real patients and the result might depend on whether the case was simple or difficult. Today many schools are trying to make assessment objective by using rubber models of the abdomen and pelvis, but these are expensive and the techniques of examining them are different from those required in practice.
      Most undergraduates enjoy obstetrics and gynaecology because it brings them into close contact with real life. In many schools our specialty is no longer part of the final examination and if we are to recruit the best students we must ensure that we maintain contact with them after their formal attachment is over, so that the distractions of medicine and surgery do not make them forget us. And we should make a special effort to attract male and female graduates in equal numbers.
      What's new?: Students used to be taught that venous thrombosis was rare and unpredictable and caused death without warning. All these “facts” were incorrect. Venous thromboembolism has been the leading direct cause of maternal death in the UK for over 20 years and important lessons have emerged from analysis of these fatal cases. Most of the women who die have obvious risk factors and most of the deaths are preceded by symptoms and signs which should lead to prompt treatment—if they are recognised. We are therefore very pleased to publish (page 3) a comprehensive review of this important topic by Peter Clark of Dundee, UK, which sets out the risk factors and the evidence base for prophylaxis and treatment. In the past obstetricians were reluctant to use anticoagulants in pregnancy for fear of causing haemorrhage but we now have good evidence for the safety and effectiveness of low molecular weight heparins. Vigilance is essential if lives are to be saved and we hope Dr Clark's review will be widely read.
      On page 11. Rody and colleagues from Frankfurt, Germany, discuss a new strategy for the classification of breast cancer, a disease which is known to be very heterogeneous. The breast contains its own stem cells which can reconstitute a complete mammary gland in vivo and breast cancers can be divided into “stem cell like” (SCL) and non-SCL tumours. SCL tumours may in turn be subdivided into estrogen-receptor (ER) positive and ER-negative tumours, the latter showing high proliferation. Among non-SCL tumours, however, the link between proliferation and ER-negativity is uncoupled. The Frankfurt group have identified a receptor, “Plexin-B”, whose expression is reduced in “uncoupled” tumours and whose loss is associated with a poor prognosis. This paper gives the reader the feeling that we are moving closer, albeit slowly, to a full understanding of this disease.
      Obstetrics and Maternal–Fetal Medicine: Preterm delivery is still a challenge and one of the most difficult aspects is prolapse of the amniotic sac into the vagina. When this occurs in the second trimester the outlook for the fetus is bleak and the obstetrician feels that action must be taken. Replacement of the sac and cervical cerclage, however, carry risks to the mother and fatalities have been reported from subsequent sepsis. On page 32 Stupin and colleagues from Berlin report a retrospective review of 182 women admitted with amniotic sac prolapse between 17 and 26 weeks’ gestation over a 15-year period from 1989 to 2005. Conservative management was followed in 72 cases and operative management in 89. The results show a clear advantage of operative treatment in terms of prolongation of the pregnancy, increased birth weight and reduced perinatal mortality. This large study adds to the existing evidence in favour of operative intervention.
      Prophylaxis against Rhesus (Rh) isoimmunisation is one of the major success stories of our specialty but there are still aspects which give rise to controversy. Twenty years ago routine antenatal prophylaxis was recommended in the UK for all Rh-ve women in their first pregnancy but 6 years ago the UK National Institute for Clinical Excellence (NICE) recommended universal antenatal prophylaxis for all at-risk Rh(D)-ve pregnant women, irrespective of parity. On page 38 MacKenzie and colleagues from Oxford, UK, report a retrospective study of 15,500 pregnancies in Rh(D)-ve women between 1990 and 2003, when only primigravid women were offered prophylaxis. The authors identified only eight women sensitised during their third or subsequent pregnancy and only one of these had received routine prophylaxis. Prophylaxis in a first pregnancy may have a long-term effect by some unexplained mechanism and the authors argue that universal prophylaxis may be a waste of resources.
      Controversy also exists over routine screening during pregnancy to detect vaginal or anal carriage of Group B streptococci, an important cause of neonatal infection. Screening is recommended in the USA but not in the UK. On page 43 Arya and colleagues from Cork, Ireland, report a prospective study of 600 women attending antenatal clinics. At 35–37 weeks self-collected ano-vaginal swabs were compared to swabs taken by a health professional. The two methods were broadly similar in accuracy but interestingly, women generally preferred to have the swabs taken by a health professional.
      Reproductive Medicine and Endocrinology: Polycystic ovary syndrome (PCOS) seems so common that we may almost regard it as a normal variant rather than a disorder. Its prevalence, however, depends on how it is defined, and early studies based on ultrasound criteria have now been overtaken by studies using clinical and endocrine criteria, which give an overall prevalence in the range of 5–10% of women. Variations within this range may be partly due to differences among ethnic groups. On page 59 Chen and colleagues from Guangzhou, China, report a population-based study of 915 women undergoing routine annual physical examination in Southern China. They found a prevalence of only 2.2% of PCOS in this group. Ethnicity affects the prevalence of hirsutism in PCOS so Ferriman–Galwey scores were not used as a criterion in this study. The authors conclude that ethnic differences should be considered when studying PCOS in China.
      Monthly vaginal bleeding is widely seen as sign of good health and in the past women have been reluctant to adopt contraceptive methods which cause amenorrhoea. In recent years, however, there has been increasing acceptance of long-acting hormonal contraception. Most of these methods have utilised progestagens but newer methods offer combined oestrogen–progestagen contraception. One of these is NuvaRing, a flexible vaginal ring which is inserted once a month and releases a low daily dose (15 mcg) of ethinyl oestradiol along with 120 mcg of etonorgestrel. On page 65 Bruni and colleagues from Italy report good results in a Phase III multicentre study of 878 cycles in 165 volunteers, who experienced satisfactory cycle control and no pregnancies.
      Gynaecology and Gynaecological Oncology: Endometriosis is the subject of several papers this month, covering a wide spectrum of research from psychology to molecular biology. It has long been taught that the severity of pain from endometriosis is unrelated to the extent of the disease, and on page 100 Eriksen and colleagues from Denmark investigate the possibility that this may be due to psychological factors. They studied 63 women with laparoscopically diagnosed endometriosis, of whom 20 were symptom-free. On psychometric testing there was no association between pain and depression or anxiety but there was an association between coping styles and emotional functioning. The authors suggest reinforcing active pain-coping skills to supplement or even replace other treatments for pain.
      A frequent complaint among patients with endometriosis is that their primary care physician took a long time to refer them to a specialist. On page 111 Denny and Mann from a dedicated endometriosis clinic in Birmingham, UK, report interviews with 30 patients, all of whom had laparoscopically diagnosed endometriosis. Some reported a positive relationship with their general practitioner but over half reported negative experiences which they felt had delayed their diagnosis. The authors call for more detailed and sensitive history taking.
      Patients’ perceptions are also the subject of a study by Tahseen and Reid from Luton and Dunstable, UK (page 90). Many women find their first attendance for colposcopy very stressful, particularly if they think they may already have cervical cancer. An information leaflet explaining that the purpose of colposcopy is to prevent cancer was perceived to be helpful but its benefit was less among women who were already very worried. A video-screen display of the colposcopy was also less helpful to very worried women than to others. The authors suggest focussing attention on these extremely anxious women.
      Another challenge to current guidelines comes from Bano and colleagues from Lewisham, London (page 86), a deprived area in which a high proportion of teenagers are involved in sexual activity. In the UK cervical screening is now recommended from age 25 rather than 20 but this guideline is not being applied in Lewisham. The authors reviewed 2793 smears in women aged under 25 and found that 182 had been referred for colposcopy, of whom 62 had high-grade precancerous lesions (CIN2 or 3). The incidence of CIN2/3 was 3.7/1000 women aged 16–25 in this population. This study shows the dangers of applying national guidelines to vulnerable people.
      Letters to the Editor: At a recent editorial meeting it was decided that in future we shall offer readers the opportunity to discuss papers on our website. This will allow more prompt comments and responses and we shall then cease publishing such correspondence in the printed journal.