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Speciality Spotlight
Women’s
Health
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Albertazzi P, Pansini F, Bonaccorsi G, et al [ Univ of Ferrara; Ferrara Research Consortium; Univ of Bologna, Italy]
The Effect of Dietary Soy Supplementation of Hot Flushes
Obstet Gynecol 91: 6-11, 1998
It is not possible to treat some women with hormone replacement therapy [HRT]. Less than 25% of Japanese women develop hot flushes, whereas 85% of North American do. 51 women between the group of 45-62 received 60 g of soy protein and 53, 60 g of placebo. Both groups had severe hot flushes.
40 patients on soy and 39 on placebo completed a 12 week period of treatment. Considerable improvement 45% was noted in the treated group and 30% in the
placebo group. 11 women on treatment and 14 on placebo developed intestinal side effects and could not complete the treatment.
Treatment with soy protein though slow has shown an impressive result.
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Huang Z, Hankinson SE, Colditz GA, et al (Harvard School of Public Health, Boston; Harvard Medical School, Boston; Brigham and Womens Hosp, Boston)
Dual Effects of Weight and Weight Gain on Breast Cancer Risk
JAMA 278: 1407-1411, 1997
In a large study the authors point out that putting on weight after 18 years of age increases the breast cancer risk not in premenopausal group but in the postmenopausal one. Hormonal replacement increases the risk.
They suggest avoidance of weight increase and hormone replacement therapy.
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Breast Cancer
Malone KE, Daling JR, Thompson JD, et al (Fred Hutchinson Cancer Research Ctr, Seattle)
BRCA1 Mutations and Breast Cancer in the General Population: Analyses in Women Before Age 35 Years and in Women Before Age 45 Years With First-Degree Family History
JAMA 279: 922-929, 1998
6.2 per cent of 193 women with breast cancer before the age of 35 years had germline BRCA1 mutations and before the age of 45 years in 208 women it was 7.2 per cent.
Mutations were more frequent if 1 or more relative below the age of 45 years had breast or ovarian cancer. Bilateral breast cancer by itself did not suggest gene mutation.
In general mutation as a cause became less with increasing age. An early onset and a strong family history of breast cancer suggest BRCA1 mutation.
The authors suggest a general screening test, yet to be developed for mass screening.
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Breast Cancer
Roohan PJ, Bickell NA, Baptiste MS, et al (New York State Dept of Health, Albany)
Hospital Volume Differences and Five-Year Survival From Breast Cancer
Am J Public Health 88: 454-457, 1998
Hospitals doing breast surgery were graded into very low volume (10/yr), low (11-50/yr), moderate (51-150/yr) and high more than 150/yr.
Survival was the best in the high volume group. Associated teaching though usual in these did not alter the results.
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Breast Cancer
Nattinger AB, Hoffmann, RG, Howell-Pelz A, et al (Med College of Wisconsin, Milwaukee; Univ of Texas, Galveston)
Effect of Nancy Reagan’s Mastectomy on Choice of Surgery for Breast Cancer by US Women
JAMA 279: 762-766, 1998
Health care may be affected if the famous undergo treatment that departs from the usual.
Nancy Reagan after an open biopsy was subjected to a modified radical mastectomy. The generally accepted breast conserving surgery was subsequently resisted by about 25% of patients. They belonged to a group identifying themselves with her belonging to the less educated or the poorer groups.
The authors conclude that celebrity may play a role model. The phenomenon is temporary but important enough to be recognized.
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Breast Cancer
Potosky AL, Merrill RM, Riley GF, et al (Natl Cancer Inst, Bethesda, Md; Health Care Financing Administration, Baltimore, Md; Group Health Cooperative of Puget Sound, Seattle; et al)
Breast Cancer Survival and Treatment in Health Maintenance Organization and Fee-for-service Settings
J Natl Cancer Inst 89: 1683-1691, 1997
The authors compare the outcome of breast cancer patients treated under the health maintenance organization (HMO) with the fee-for-service (FFS) way. In a large study the HMO patients were younger, diagnosed in earlier stages and breast conserving surgery was more practicable as was subsequent radiotherapy.
In the FFS group patients were older, had other morbidity and breast conserving surgery was possible less often.
They conclude that the long term survival was roughly the same in the two systems. Cost effectivity favors the health care organizations.
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Breast Diseases
Harvey JA, Moran RE, Maurer EJ, et al (Univ of Virginia, Charlottesville)
Sonographic Features of Mammary Oil Cysts
J Ultrasound Med 16: 719-724, 1997
Fat cell breaks due to injury from oil cysts and with subsequent fibrosis they are felt as lumps in the breast.
Radiolucency is a typical mammographic appearance and sonography produces an intracystic mass that is hypoechoic.
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Eaker ED, Vierkant RA, Konitzer KA, et al (Univ of Wisconsin, Madison)
Cervial Cancer Screening Among Women With and Without Hysterectomies
Obstet Gynecol 91:551-555, 1998
The authors compare the number of Pap smears performed in women with or without a hysterectomy.
They conclude that smears were studied more often if malignancy was the cause of hysterectomy, than a benign condition.
In general they felt that 2 to 3 times more smears are being done than is required.
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Cervical Cancer
Cantor SB, Mitchell MF, Tortolero-Luna G, et al (Univ of Texas, Houston; Univ of Texas, Austin)
Cost-Effectiveness Analysis of Diagnosis and Management of Cervical Squamous Intraepithelial Lesions
Obstet Gynecol 91: 270-277, 1998
Women with positive Pap smears have to spend considerable amount of time and money on their treatment and diagnosis.
Cost effective and efficient methods of diagnosis of cervical squamous intraepithelial lesions (SILs) with colposcopy, fluorescent spectroscopy and loop electrosurgical excision procedure (LEEP) are evaluated.
Colposcopic biopsy was the most informative and expensive. Fluorescent spectroscopy and LEEP were lowest on both counts.
The authors found a combination of both to be more efficient than colposcopic biopsy, hence recommend the procedure.
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Cervical Cancer
Tate KM, Strickland JL, (Univ of Missouri Kansas City School of Medicine)
A Randomized Controlled Trial to Evaluate the Use of the Endocervical Brush After Endocervical Curettage
Obstet Gynecol 90: 715-717, 1997
Material taken with a Kevorkian endocervical curette is often inadequate for pap studies.
According to the authors the use of an endocervical brush after the curette reduces inadequacy from 10 to 0.
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GjÆnnaess H (Aker Univ Hosp, Oslo, Norway)
Late Endocrine Effects of Ovarian Electrocautery in Women With Polycystic Ovary Syndrome
Fertil Steril 69: 697-701, 1998
Laparoscopic guided electrocautery of polycystic ovaries of women suffering thus results in reduction of serum levels of androgens and gonadotropins.
This converts anovulatory to ovulatory cycles in a very high proportion leading to greater possibility of pregnancy.
The authors say that the effects last for 18-20 years and early menopause is not precipitated. Adhesions with this procedure are less likely than with wedge resection.
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Polycystic Ovaries
Morin-Papunen LC, Koivunen RM, Ruokonen A, et al (Univ Central Hosp of Oulu, Finland)
Metformin Therapy Improves the Menstrual Pattern With Minimal Endocrine and Metabolic Effects in Women With Polycystic Ovary Syndrome
Fertil Steril 69: 691-696, 1998
4-6 months treatment with metformin in a dose of 500 mg thrice a day for polycystic ovary syndrome in obese women resulted in replacement of irregular cycles with a more normal pattern.
Along with this testosterone levels in the serum decreased. This improvement was noticed at the end of 2 months but could not be sustained till the end of treatment (4-6 months).
All other parameters e.g. obesity, hirsutism and abnormalities in lipid levels remained unchanged. Return of menstrual cycle to normal may suggest increase in fertility.
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Thys-Jacobs S, and the Premenstrual Syndrome Study Group (St. Luke’s-Roosevelt Hosp Ctr, NY)
Calcium Carbonate and the Premenstrual Syndrome: Effects on Premenstrual and Menstrual Symptoms
Am J Obstet Gynecol 179: 444-452, 1998
The authors have used 1,200 mg of elemental calcium (TUMS E-X) per day with placebo control in this study. An everyday record of symptoms including menstrual bleeding were kept by the subjects.
Marked reduction of symptoms was observed during the luteal phase of the cycle, especially in the second and third months.
48 per cent on treatment showed the effects against 30 on placebo. This approach may prevent osteoporosis too. More work is required to substantiate the results.
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Schmidt PJ, Nieman LK, Danaceau MA, et al (Natl Inst of Mental Health, Bethesda, Md; Natl Inst of Child Health and Human Development, Bethesda, Md)
Differential Behavioral Effects of Gonadal Steroids in Women With and in Those Without Premenstrual Syndrome
N Engl J Med 338: 209-216, 1998
Effects of estrogen and progesterone in causation of the premenstrual syndrome (PMS) are studied between the age groups of 27-45 years (mean 37).
After estradiol and progesterone plasma levels three groups were created. Group 1 received leuprolide acetate injections in a dose of 3.75 mg every month, 2 was a placebo of normal saline and 3rd was given progesterone or estradiol as well as leuprolide.
Evaluation at 3 months showed leuprolide (a gonadotropin-releasing hormone) alone to give the best results. It was continued in those who responded to it for 3 months more. The authors suggest that normal plasma levels of gonadal hormones lead to abnormalities in some women.
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Contraception
Glasier A, Baird D (Edinburgh Healthcare Natl Health Service Trust Family Planning and Well Woman Services, Scotland; Univ of Edinburgh, Scotland)
The Effects of Self-administering Emergency Contraception
N Engl J Med 339: 1-4, 1998
To avoid pregnancy the tablets have to be taken within 72 hours of intercourse. As a prescription is necessary many women are not in a position to take advantage of this facility.
The authors conclude that if these hormonal tablets were kept at home for emergency use results could be improved upon.
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Abortion
Creinin MD, Shulman T (Univ of Pittsburgh, Pa)
Effect of Nonsteroidal Anti-inflammatory Drugs on the Action of Misoprostol in a Regimen for Early Abortion
Contraception 56: 165-168, 1997
This article quotes 3 trials on the use of Methotrexate in a dose of 50 mg/m2 intramuscularly followed by 800 mg of misoprostol vaginally after 7 days repeated in case of failure to abort. The latter drug was also used alone. The fetal age was 56 days or less.
Use of ibuprofen and acetaminophen with codeine phosphate did not interfere with the desired effects.
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Menopause
Uyama O, Yoshimoto Y, Yamamoto Y, et al (College of Nursing Art and Science Hyogo, Akashi, Japan)
Bone Changes and Carotid Atherosclerosis in Postmenopausal Women
Stroke 28: 1730-1732, 1997
Women between the ages of 67-85 were studied. Bone density and ultrasound studies for the carotid arteries were carried out.
The authors conclude that the two are closely related and the presence of one should suggest the other in the elderly.
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Alternate Medicine
Hirata JD, Sweirsz LM, Zell B, et al (Kaiser Permanente Med Ctr, Oakland and Richmond, Calif)
Does Dong Quai Have Estrogenic Effects in Postmenopausal Women?
A Double-blind, Placebo-controlled Trial
Fertil Steril 68: 981-986, 1997
Dong quai is one component of other root preparation combined medicine. This combination is believed to reduce postmenopausal symptoms.
Used alone no estrogenic effects were found on the vaginal epithelium or the endometrial lining nor the symptoms. Headache, burping and gaseous distension were compared of on the normal dose of 4.5 gm/day of the root.
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Hormone Replacement Therapy
Col NF, Eckman MH, Karas RH, et al (Tufts Univ, Boston; Univ of Massachusetts, Worcester; Fallon Health Care System, Worcester, Mass)
Patient-specific Decisions About Hormone Replacement Therapy in Postmenopausal Women
JAMA 277: 1140-1147, 1997
Hormone replacement therapy reduces the risk of coronary heart disease (CHD). Risk factors for the latter in postmenopausal women include hypertension, hypercholesterolemia and smoking.
These have to be balanced against a family history of breast cancer in 2 1st degree relatives or a history of endometrial malignancy.
The authors conclude that all postmenopausal women would be helped by HRT but those prone to malignancy of the breast or endometrium cannot be treated thus.
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Hormone Replacement Therapy
Pickar JH, for the Menopause Study Group (Wyeth-Ayerst Research, Philadelphia; Eastern Virginia Med School, Norfolk)
Is Bleeding a Predictor of Endometrial Hyperplasia in Postmenopausal Women Receiving Hormone Replacement Therapy?
Am J Obstet Gynecol 177: 1178-1183, 1997
Used alone estrogen leads to endometrial hyperplasia resulting in bleeding. Those taking medroxyprogesterone acetate as a combination treatment, intermittently or continuously did not develop endometrial hyperplasia.
In these subjects if bleeding occurred other causes need to be looked into.
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Vaginal Bleeding and HRT
Ettinger B, Li D-K, Klein R (Kaiser Permanente Med Care Program, Oakland, Calif)
Unexpected Vaginal Bleeding and Associated Gynecologic Care in Postmenopausal Women Using Hormone Replacement Therapy: Comparison of Cyclic Versus Continuous Combined Schedules
Fertil Steril 69: 865-869, 1998
Unexpected vaginal bleeding is seen less often in the postmenopausal untreated than in those on cyclic hormone replacement therapy (HRT).
Comparing cyclic-HRT with continuous use, the authors find that during the first 2 years both groups need gynecologic monitoring (resources, time and visits), but after 2 years continuous users need less surveillance. With intermittent therapy adjustment is slower.
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Pelvic Examination
Campbell KA, Shaughnessy AF (Harrisburg Family Practice Residency Program, Pa)
Diagnostic Utility of the Digital Rectal Examination as Part of the Routine Pelvic Examination
J Fam Pract 46: 165-167, 1998
As digital rectal examination is a non expensive procedure it is included in routine pelvic examination in women of all age groups.
Below 40 years its value was negligible, and discomfort produced was considerable.
The authors suggest its deletion in routine pelvic examination.
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Wu V, Farrell SA, Baskett TF, et al (Dalhousie Univ, Halifax, Nova Scotia, Canada)
A Simplified Protocol for Pessary Management
Obstet Gynecol 90: 990-994, 1997
Except with total vaginal eversion the degree of prolapse did not come in the way of pessary fitting. Women with urinary incontence did not accept a pessary; they opted for surgery.
The authors conclude that pessaries can be safely used on a long term basis for pelvic prolapse.
