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April 2009 Newsletter Major Addition to the 2 Womenshealth Newsletter.
From April 2009, selected questions sent to me will be added to the newsletter and evidence based answers provided.
To preserve anonymity, minor changes to the question may be made.
If you have a question, please write to me - david@2womenshealth.com
Naturally, I will only be able to answer questions of a general nature.
Question 1
"Something coming down"
"I am a 59 year old women who is fairly active and healthy. I attend a High Impact session twice a week doing "Jassaize". I have noticed a strange happening which has alarmed me and feel rather embarrassed to discuss it.
On showering after the last couple of sessions, I felt something down below and was quite alarmed. I used a mirror to investigate. It looked like a ping pong ball size, white in colour and was just about hanging out from inside!
This has frightened me very much, it only seems to happen after this vigorous exercise and can be pushed back inside. Could you advise what this could be, before visiting my doctor.” -- UK
Answer
Thank you for your question.
Your symptom presents frequently in gynaecology clinics.
The story is typical of
utero-vaginal prolapse although without an examination,
no doctor could be certain.
The uterus and vaginal walls are supported by a system of ligaments. During childbirth, these ligaments are stretched and may be weakened. The health of the ligaments is influenced by the female hormone called oestrogen. Following the menopause, oestrogen levels fall. It is, therefore, understandable that prolapse problems tend to arise within a few years of the menopause and particularly in ladies who have given birth.
Prolapse in itself is not life-threatening and treatment options depend on symptoms. Frequently, women without symptoms are found to have a prolapse during a routine pelvic examination. Treatments can only reduce symptoms and if there are no symptoms there is no reason to treat.
If a prolapse is causing problems then either an internal support (vaginal ring pessary - picture on right) or surgery (pelvic floor repair) are the options. If surgery is required, the prolapsing "parts" are supported into their correct positions. If the uterus is coming down, then it may need to be removed vaginally - vaginal hysterectomy.
Question 2
"Recurrent Early Miscarriage" - Middle East
My wife is aged 40 years old we have been married for the last 4 years. In the first year she had a successful pregnancy and she delivered a healthy baby.
In 2008 she was pregnant and we followed her with ultrasound examination and we discovered that there is no progress; we followed her to 9 weeks and it was a missed abortion.
The same story repeated itself this year.
I need your advise what investigations should be done to know the cause of her recurrent missed abortion.
Answer
Thank you for your question.
The definition of
recurrent miscarriage (abortion) is three consecutive
early pregnancy losses. The above story, however saddening it may be, is not
recurrent miscarriage as there have not been three miscarriages.
Miscarriage is an emotionally challenging ordeal accompanied by all the feelings of bereavement. When it occurs more than once it may, understandably, be a particularly devastating experience. Most experts suggest that investigations to detect the cause of recurring miscarriage should begin after three consecutive pregnancy losses. For those who have miscarried twice, this seems harsh. If we are pedantic, when something recurs it has happened more than once so the second miscarriage is obviously a recurrence. Some departments, have revised their criteria so that consultation and some investigations can commence after two consecutive miscarriages. This can, however, lead to problems.
As the majority of pregnancies, even after three miscarriages, are likely to be successful, it is particularly difficult to scientifically prove that a particular treatment is effective. The one cause of miscarriage that can be detected and for which there is effective treatment is increased levels of 'antiphospholipid antibodies'. The blood tests are for lupus anticoagulant and anticardiolipin. If these prove to be positive, Aspirin (75mg daily) particularly in combination with heparin, significantly reduces the likelihood of miscarriage - this is evidence based medicine. During that next pregnancy, increased monitoring would be undertaken and the threshold for obstetric interventions, including induction of labour and caesarean section, would be lowered. These treatments have been proven to be beneficial for those who have had three consecutive miscarriages but benefit has yet to be confirmed for those who have had less than three consecutive pregnancy losses - we are potentially putting ourselves into suggesting treatment without evidence of benefit.
The incidence of early pregnancy loss doubles from the age of 20 to 40 years and evidence from IVF with egg donation suggests that increased miscarriage problems in older women may be partly attributable to the state of the uterus. A recent study in Bologna, Italy compared implantation and pregnancy rates in an oocyte donation programme with women of different ages sharing oocytes from the same donor: clinical pregnancy rates and ongoing pregnancy rates were twice as likely in recipients of less than forty years old compared to older recipients.
The recommended investigations for recurrent miscarriage include:
- Pelvic Ultrasound - looking for uterine abnormality such as fibroids and the ovaries for PCO.
- Female hormone profile (Day 2-6 of menstrual cycle - High LH may suggest PCOS and High FSH may indicate that the menopause is approaching. Elevated androgens may indicate PCOS - Treatment of PCOS has not consistently been shown to reduce miscarriage rates.
- Blood Glucose - For evidence of diabetes
- Full Blood Count - looking for anaemia
- Chromosome analysis both partners - looking for genetic abnormality that may lead to miscarriage.
When there has been a successful pregnancy, as in the above patient story, genetic problems and uterine abnormality are less likely.
J Rheumatol. 2009
Interestingly, in a 2009 study, heparin and aspirin did not confer incremental benefit compared to aspirin alone.2009 Regardless of treatment regimen, number of prior losses, or aPL positivity, almost 80% of women in our recurrent pregnancy loss cohort had a successful pregnancy outcome. These findings contribute to a growing body of literature that contests the emerging standard of care comprising LMWH/ASA for this population.
Question 3 Progestogen-Only Oral Contraception
I am about to start taking Cerazette, Desogestrel. Within the last week I have finished a period. Can I start taking the pill immediately? If so, when will I be protected?
Answer
Thank you for your question.
Cerazette is a progestogen only pill. The progestogen-only pill can be commenced on the first day of a period and it will then provide immediate protection. Perhaps the best option now is to use a barrier method through this cycle and start the pill on the first day of your next cycle.
PCOS associated infertility - The role of metformin
Although the exact causation of
PCOS is not yet fully known, insulin
resistance is believed to be a major contributory factor. From the late 1990's,
metformin has become popular treatment of PCOS related anovulatory infertility
because it increases insulin sensitivity and therefore reverses the underlying
problem. Many of us who have used metformin for this purpose have been
impressed by its clinical benefits. It takes large
randomised controlled studies to
provide scientific evaluation of treatments.
Research from 2007, has questioned the value of metformin for women with PCOS and infertility. In one study,0801 The ovulation rate was 23.7% in a metformin group, 59% in a CC group, and 68.4% in the combination treatment group. This was translated into a similar PR and live birth rate, which were higher in the CC and combination groups compared to the metformin group, although statistically the differences were not significant. There were no multiple pregnancies and the rate of spontaneous first trimester loss was similar to the general population. According to a recent concensus,0802 metformin use in PCOS should be restricted to women with glucose intolerance. Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended.
More recently, (2009) there has been a more optimistic evaluation of randomised controlled trials assessing the value of metformin in the management of PCOS associated infertility. In PCOS patients with anovulatory infertility and not previously treated, the administration of metformin plus CC is not better than monotherapy (metformin alone or CC alone), whereas to date no specific recommendation can be given regarding the use of CC or metformin as first-step drug.0901
Ovarian Cancer Screening
The ovaries are situated deep in the pelvis and when cancer develops it grows silently so that diagnosis has tended to be late - treatment success is dependent on early diagnosis.
Pelvic ultrasound provides a window onto the ovaries. Whereas, taking a cervical smear is a fairly quick and simple procedure that most general practitioners and some nurses can do, pelvic ultrasound is restricted to those who have had extensive training and takes 10 -15 minutes. Ovarian cancer tends to be associated with tumour markers such as Ca125 that can be detected in a blood sample so that screening for early ovarian cancer has become a major issue in women's health.
Two large studies have recently reported their results on screening. The
study in London0901
shows a little reason for optimism whereas an American Study0902
shows a relatively high incidence of surgery with little benefit. No study
of ovarian screening to date has demonstrated any proof of benefit in terms of
reduced mortality.
Lancet Oncol. 2009 - 0901
The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is a randomised controlled trial designed to assess the effect of screening on mortality.
Between 2001 and 2005, over 200,000 women aged between 50 and 74, received either no screening, yearly screening by ultrasound scan, or a blood test with an ultrasound for those at high risk. Screening led to surgery in 1.8% of women in the ultrasound group and 0.2% of women in the combined test/ultrasound group. Of these women receiving surgery 89% were found to have non-cancerous abnormalities, with most of these being in the ultrasound-only group. The results demonstrate the problem with some screening tests, in that early cancer detection needs to be balanced against potentially treating women unnecessarily.
This trial is ongoing, and long-term survival rates for these women will be published in the future.
The results of the study
Within each screening group, 98.9% women received the combined screening (CA125 blood test with/without ultrasound) that they were randomised to receive, while 95.2% of women randomised to receive ultrasound-only were scanned.
Of all women who received surgery, 834 (47 of the combined screen group; 787 of the ultrasound group) were found to have benign (non-cancerous) growths or normal ovaries, and of these 24 (2.9%) had a major complication as a result of surgery.
Cancers of the ovaries or fallopian tubes were detected in 87 women undergoing surgery (42 in the combined screen group and 45 in the ultrasound group). There was a significant difference in the specificity of the two tests. The ultrasound-only screen had lower specificity than the combined screen, i.e. women who did not have ovarian cancer were more likely to have an ultrasound scan incorrectly detecting cancer, leading to further unnecessary assessment and surgery.
Conclusion
In the UK this week, the country has mourned the loss of a 27 year old star - Jade Goody from cervical cancer. Cervical cancer develops initially with pre-malignant changes. Samples of surface cells from the cervix - Pap Smear Test can pick up problems in the pre-malignant stage and this is amenable to preventative out-patient treatment. Jade in her last months highlighted the need to pursue screening tests to reduce preventable cancer in women.
Whilst there is some optimism from the new ovarian cancer screening study results, a lot more work is required to reduce the consequences of ovarian cancer.
Obstet Gynecol 2009 0902
In the USA screening for ovarian cancer was carried out with both transvaginal ultrasonography and the serum biomarker CA 125 in 34,000 women, and the results are reported in the April issue of Obstetrics & Gynecology.
Any test that is designed or that is being used to detect ovarian cancer must have a high sensitivity and specificity to have a positive-predictive value that is sufficient to make it worthwhile to perform a relatively risky procedure (surgical removal of the ovaries) on a patient with a positive test.
The definitive measure of whether any test is a good clinical screening test is a reduction in the mortality rate.
The majority of cancers identified in this study were late stage (III or IV), when effective treatment is limited.
Benefits from the test should be achieved at an acceptable level of risk. The prevalence of ovarian cancer is very low, no test has been shown to alter the natural course of the disease, and the intervention used to evaluate a positive screen — oophorectomy — carries significant morbidity and even mortality.
This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.
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