Editorial| Volume 153, ISSUE 1, P1-2, November 2010

Editor's highlights

Published:September 09, 2010DOI:
      The specialty of obstetrics and gynaecology is of public interest. Every day newspapers carry articles about women's health, such as stories of a safe delivery in unusual circumstances or a bad experience for which a hospital or doctor is being blamed. In general, obstetricians are wary of talking to the media, but medical journals are less shy. Researchers like it when their papers attract attention and many universities seek publicity for their staff. Some journals issue regular press releases highlighting papers which the editor thinks are interesting. This is not the policy of the EJOGRB. Our reluctance is partly because we would have to issue statements in the 23 official languages of the European Union but mainly because we feel selective publicity is not in the public interest. Press releases are often used by journalists who have little scientific knowledge and rarely read the original paper. This leads to distorted information in the form of unnecessary health scares or false hopes of an imminent “medical breakthrough”. An interesting study on how the media deal with women's health is published in this issue, as mentioned below.

      What's new?

      Tattoos used to be the mark of a sailor but over the last 20 years they have greatly increased in popularity among men and women of almost all demographic groups. “Body alteration” or “body art” may sometimes be a source of concern during pregnancy. These issues are reviewed on page 3 by Nicolas Kluger from Montpellier, France. It appears that piercings involving the tongue, navel, nipples or genitals cause little trouble to the obstetrician. Removal may not be necessary and a non-judgemental approach is recommended. Oral and nasal jewelry, however, may cause problems for the anaesthetist, and women should be asked at the beginning of pregnancy if they have piercings. Tattoos are relatively infrequent in the lower abdominal region but are more common in the lumbar area, where they may deter the anaesthetist from performing an epidural. Such anxiety is unjustified and the author strongly advises performing neuraxial blockade through the tattoo.
      Around 2% of women who undergo cervical screening are found to have low-grade squamous intraepithelial lesions (LSIL). More than 80% of women with LSIL have human papillomavirus (HPV), though the distribution of HPV types varies in different studies. There is a high risk of transmission of HPV to the male partner, and on page 8 Simon and colleagues from Brussels discuss whether this represents a clinical risk to him as well as to the woman. Among women the clearance rate of HPV is high, though it is lower in cases of HPV 16 infection. Among men HPV16 is the most frequently encountered type but clearance is rapid. Condom use not only prevents infection but also accelerates the clearance rate of both cervical and penile lesions. The authors conclude that there is little benefit in vaccinating the male partner of an LSIL patient.

      Obstetrics and maternal-fetal medicine

      Prevention of preterm birth has been the goal of much research and although results have often been disappointing there are some grounds for optimism. It is now clear that infection is a causative factor but studies focused on screening for bacterial vaginosis have produced mixed results. Six years ago a randomized controlled trial (RCT) from Vienna showed that integrating a simple infection screening programme into routine antenatal checks led to a reduction in preterm births. It is one thing, however, to demonstrate a significant result in an RCT and another to show that treatment is effective in routine practice. Now Kiss and colleagues, the authors of the original RCT, report (page 38) what happened when the screening programme was introduced in their unit. They compare 1273 women presenting after 1 September 2004 with a control group of 1713 women studied two years previously. The rate of preterm delivery was reduced from 12.1% to 8.2%, and the rate of very preterm delivery (<33 weeks) from 5.4% to 1.9%. These results, say the authors, are generalisable to other countries.
      Obesity carries maternal and fetal risks in pregnancy and is becoming more common in developed countries. On page 43. Mantakas and Farrell from Sheffield, UK, report a retrospective review of 6509 nulliparous women with singleton pregnancies booked for delivery at one hospital between 2001 and 2008. They divided the subjects into five groups according to BMI. Morbid obesity was defined as BMI >40 and there were 105 women in this group. The caesarean section rate was 18.2% in women of normal BMI and 40.6% among morbidly obese women, who had a relative risk of stillbirth of 16.7. The risks of fetal macrosomia and shoulder dystocia were also related to increasing BMI. Recent guidelines state that all women should have their BMI calculated at the start of pregnancy and that sensible advice on weight reduction should be offered where appropriate. The authors comment that it remains to be seen whether specialist antenatal clinics for women with raised BMI will improve pregnancy outcome.
      Knowledge about HIV infection has progressed rapidly over the years. Caesarean section (CS) reduces the risk of vertical HIV transmission and although it is no longer recommended for every HIV-infected woman, it is nevertheless widely chosen by patients and professionals. Maiques and colleagues from Valencia, Spain, report (page 27) that in a large cohort of HIV-infected women only 19% chose vaginal delivery. The worry is that impaired immune function of HIV-infected women may put them at increased risk of complications from CS compared to non-infected women. The authors compared 160 HIV-infected women on highly-active antiretroviral therapy and 320 non-infected women undergoing CS in a single centre between 1997 and 2007. Prematurity and low CD4+ cell count were risk factors for major complications but there was no significant difference in complication rates between the two groups.

      Reproductive medicine and endocrinology

      Media coverage of medical matters is of variable quality, as mentioned above. The information given is sometimes accurate and informative but often is not, and the consequences of distorted reporting can be damaging to women. Risks and benefits of hormone replacement therapy have been a confusing issue even for health professionals so it is not surprising that they have also confused the public. On page 56 Colombo and colleagues report a study of 225 articles in Italian magazines, newspapers and journals on this topic between 2000 and 2007. Articles were assessed by five professional medical journalists and one clinician, using a form which dealt with graphic layout, clarity of language and completeness of information. The jury judged that 70% of the articles in specialised journals but only 25% of those in women's magazines were helpful to women trying to make informed decisions. The authors comment that articles need to report absolute rather than relative risks, that scientific journalism needs to grow through training and that researchers could also benefit from training in how to deal with journalists. It is planned that dissemination of these wise recommendations will be properly evaluated.

      Gynaecology and gynaecological oncology

      Postmenopausal bleeding (PMB) is a common symptom. The prevalence of endometrial cancer in women with PMB varies between 3% and 10% in various studies. Management also varies, with different combinations of ultrasound, hysteroscopy and endometrial biopsy being used. On page 67 Ewies and Musonda from the UK evaluate a “one-stop PMB clinic” which uses transvaginal ultrasound scanning (TVS) with or without Pipelle endometrial biopsy as the first-line investigation. The authors carried out a retrospective data review of 326 women seen between August 2005 and August 2009 in this hospital clinic. Eighteen women (5.5%) had endometrial cancer and six (1.8%) had atypical hyperplasia. One case of cancer, with endometrial thickness <5 mm and negative Pipelle biopsy, was only diagnosed after curettage for persistent bleeding. The authors conclude that TVS may be adequate as a first-line investigation and that persistent bleeding should be re-investigated. Priority should be given to older women and those with multiple bleeding episodes, who are at higher risk of malignant disease.
      Acupuncture has fascinated European doctors for many years because it is based on a system of medicine that is completely different from ours. For researchers, the difficulty has been to separate the “real” effect from the placebo effect – if indeed such a distinction should be made. Rubi-Klein and colleagues from Austria and Germany present (page 90) a study of 101 women with moderate or severe pain from stage II–IV endometriosis diagnosed by laparoscopy. Patients were randomised into two groups: 47 received acupuncture according to the genuine Chinese system and 54 received non-specific acupuncture (applied to acupuncture points which were not correlated with endometriosis under the Chinese system). Ten weekly treatments were given and a crossover design was used. Eighty-three patients finished the study and the results showed benefit only from the genuine treatment. Although critics will point out that such studies cannot be double-blind, the improvements in pain relief and quality of life in this study are impressive. The authors comment that chronic pain requires longer treatment and that the cost-benefit ratio should be assessed in a further study.

      Gynaecological urology

      The effect of pregnancy and delivery on subsequent uterine prolapse has been the subject of much research, but other factors also influence the risk of prolapse. These are addressed by two papers in this issue. Intrinsic changes in the connective tissue of the pelvic floor were investigated by Liang and colleagues from Taiwan (page 94) in a study of matrix metalloproteinase, an enzyme that degrades collagen. The authors obtained paired samples of uterosacral ligament and cervical tissue from premenopausal women without prolapse and from pre- and postmenopausal women with severe uterine prolapse. Clear differences were seen between controls and women with prolapse, but not between pre- and postmenopausal women. In the second paper, the sensitivity of pelvic tissues to hormonal changes was investigated by Skala and colleagues from Mainz, Germany (page 99), using anterior vaginal wall and periurethral tissue from 89 patients undergoing vaginal urogynaecological surgery. The authors compared the expression of oestrogen and progesterone receptors in premenopausal women and postmenopausal women, half of whom were using either HRT or local oestrogen treatment. Receptor expression varied with hormonal changes, but only in vaginal wall and not in periurethral tissue. The authors conclude that vaginal tissue seems to change irreversibly during the climacteric period.
      A third study on prolapse is reported as a “Letter to the Editor – Brief Communication” on page 112. Silva-Filho and colleagues from Brazil and Portugal have developed a 3D computer model, based on MRI images, to evaluate pelvic floor muscle cross-sectional area (CSA). Using this model they compared the CSA in women with and without prolapse and found a higher levator ani CSA in the anterior compartment in women with prolapse. They comment that if this research is translated to clinical settings it may improve assessment and treatment of pelvic floor dysfunction, but larger prospective studies are needed.