Newsletter: Hysterecotomy - Menopause - Vaginal Prolapse, Miscarriage Tampons

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March 2009 Newsletter

tampons and Risk of infections

BJOG 2008

There is no evidence that a a lactic acid-buffered gel lubricated tampon product investigated by a group in Edinburgh controls vaginal pH but women preferred them to tampons without lubrication.⁰⁸⁰¹

Elevated vaginal pH (reduced acidity - a natural occurrence during and shortly after menstruation) is associated with bacterial vaginosis and it has been suggested that maintaining a low pH in the vagina might reduce the incidence of troublesome symptoms and infection of the genital tract. They assigned 98 women to use regular tampons with either a lactic acid-buffered gel (pH 3.8-4.2) or a standard lubricating gel (pH 5.1). The women used tampons without gel in the preceding cycle. No significant difference was observed between tampons with the standard gel formulation, the pH-balanced gel and non-lubricated tampons in terms of vaginal pH, microbiological evidence of Candida or bacterial vaginosis.

Women reported higher mean satisfaction scores for lubricated tampons than for non-lubricated tampons.

Although the study did not demonstrate any major benefits of tampon lubrication with a pH-balanced gel, it does provide reassuring data on the safety and the acceptability of lubricated tampons and adds to the limited volume of published literature on the effects of tampons on the vaginal milieu," the researchers concluded.

Infertility - Ovulation Induction and Ovarian Cancer - Almost certainly not a problem

BMJ 2009

In 1994, a comparison was made of the risk of cancer among women who received clomiphene with the risk among infertile women who did not receive it. There were 11 invasive or borderline malignant ovarian tumors, as compared with an expected number of 4.4^1994-01. A confounding factor is that infertility is itself associated with an increased risk.

Several infertility units have subsequently reported their data. Some seemed to confirm the link between clomiphene and ovarian cancer but the majority have produced reassuring results.^{1999-02,2004-02} ^2006-01

To examine the effects of fertility drugs on overall risk of ovarian cancer using data from 54,362 women with infertility problems referred to all Danish fertility clinics during 1963-98 were evaluated.⁰⁹⁰¹ The median age at first evaluation of infertility was 30 years (range 16-55 years), and the median age at the end of follow-up was 47 (range 18-81) years. Included in the analysis were 156 women with invasive epithelial ovarian cancer (cases) and 1241 subcohort members identified in the cohort during follow-up in 2006. The effect of four groups of fertility drugs (gonadotrophins, clomiphene citrate, human chorionic gonadotrophin, and gonadotrophin releasing hormone) on overall risk of ovarian cancer after adjustment for potential confounding factors was assessed. Analyses within cohort showed no overall increased risk of ovarian cancer after any use of gonadotrophins,, clomiphene (1.14, 0.79 to 1.64), human chorionic gonadotrophin , or gonadotrophin releasing hormone. Furthermore, no associations were found between all four groups of fertility drugs and number of cycles of use, length of follow-up, or parity. It was concluded that there is no convincing association between use of fertility drugs and the risk of ovarian cancer.

There are three concerns associated with drugs used to induce ovulation:

They are associated with a greater chance of multiple pregnancy. The general rate of twins in the population is one in every eighty deliveries but with clomiphene, it is one in twenty or a four-fold increase. Higher order multiple pregnancies (e.g. triplets and quads) can occur with clomiphene but this is rare. Injections of gonadotrophins are more likely than clomiphene to result in multiple pregnancy.
Occasionally ovulation induction can lead to ovarian hypersensitivity syndrome (OHSS).
Finally, there has been concern that ovulation induction treatments may increase the chance of ovarian cancer. The ;atest research, reported from Denmark seems to confirm that this is not a true risk.

Introduction to Hysteroscopy and D and C For Patients

BJOG 2008

Hysteroscopy procedure can help find out if there is an abnormality causing symptoms such as unusual vaginal bleeding including heavy periods and bleeding after the menopause. Usually no disease is found and you can be reassured. Pre-operative ultrasound examination is frequently arranged. Hyteroscopies can also be used to check for certain womb conditions such as polyps (small growths of tissue in the womb lining), fibroids (benign growths of muscle in the womb), heavy periods or early signs of womb cancer. Abnormalities of the endometrial cavity can be responsible for infertility or problems with recurrent miscarriage.

For diagnostic hysteroscopy, a thin hysteroscope can be used and usually not even local anaesthetic is required. For operative hysteroscopy, the cervix has to be dilated and general anaesthetic is usually employed. To make it easier, the cervix may be ripened pre-operatively and the prostaglandin called misoprostol is becoming popular.⁰⁸⁰¹Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use.

Giving Birth At Home

　BJOG 2008

Childbirth is one of the most wonderful events for most families. Many women assume they will be having their baby in hospital because that is what their friends or relatives did. or it is what they have seen on the television programmes or they have read about in books and magazines.

Those who advocate home birth claim benefits which include:

A less painful labour.
Knowing the midwives who will be at your birth.
One to one midwifery care.
More privacy and control in labour and afterwards.
Greatly reduced need for medical intervention.
Healthier outcome for mother and baby.
The baby is more likely to breastfeed.
Lower rates of postnatal infections for mum and baby.
The father is never sent away or reduced to visitor status.
The childbirth is seen as a natural event to be enjoyed by the family and an ideal way to start parenting.
A better emotional experience.
If you have other children they can be as involved as much as you want them to be.

A study in 2008 of the Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001-03) was undertaken.⁰⁸⁰¹ Low-risk women (280,097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife were evaluated. Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes. In this study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The non-urgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001).No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the non-referred group. It was concluded that risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives.

Childhood Sexual Abuse - long-term Effects on gynaecological and other problems

A 2009 study from Canada⁰⁹⁰¹has demonstrated that after childhood sexual abuse there is:-

anorexia nervosa
depression
bulimia nervosa
reduced self-esteem

and those affected might benefit from a more specialized focus on their emotional responses to the abuse including counselling.

Estimates of the prevalence of childhood sexual abuse and molestation among females in the general population vary from 7% to 38%. Rates of up to 62% have been reported when abuse not involving contact is included (such as exhibitionism or obscene phone calls).

severe premenstrual syndrome.
frequent (unspecified) gynaecological problems.
vaginal infections.
dissatisfaction with their sex life.
dyspareunia.
sexual anhedonia (anhedonia is an inability to experience pleasure from normally pleasurable life events such as eating, exercise, and social or sexual interaction),
anorgasmia.
pain disorders, including, among others, dysmenorrhoea.

Twins - Mode of Delivery of Twins - Vaginal Birth or Caesarean Section?

Perinatal mortality is five times higher in twins than in singletons. This increased risk is mostly unrelated to mode of delivery. Nevertheless, vaginal birth of twins at term is well recognised as a high-risk area. It is associated with increased rates of perinatal death primarily because of intrapartum asphyxia of the second twin. It is plausible that planned caesarean section may have a protective effect on these outcomes but there is a lack of direct evidence in this area.

A recent study from Sweden⁰⁸⁰¹ was set up to assess the association between mode of delivery and neonatal mortality in second twins. Comparison was made of the outcome of second twins delivered by caesarean due to breech presentation of the sibling with vaginally delivered second twins in uncomplicated pregnancies.

Twins born during 1980-2004 were identified from the Swedish Medical Birth Registry. Twin pairs delivered by caesarean due to breech presentation of the first twin, and vaginally delivered twins with the first twin in cephalic presentation were included. Pregnancies with antepartum complications were excluded. Compared with second-born twins delivered vaginally, second-born twins delivered by caesarean (for breech presentation of the sibling) had a lower risk of neonatal death. The decreased risk after caesarean delivery was significant for births before 34 weeks. After 34 weeks, neonatal mortality was low in both groups (0.1 and 0.2%, respectively), and the difference was not statistically significant.

It was concluded that neonatal mortality is lower for the second twin after caesarean delivery at birth before 34 weeks. At term, mortality is low irrespective of delivery mode.

Compliance With Preconception Care Advice

BMJ 2009

To examine the extent to which women planning a pregnancy comply with recommendations for nutrition and lifestyle - preconception counselling, 12 445 non-pregnant women aged 20-34 recruited to the Southampton Women's Survey⁰⁹⁰¹ through general practices, 238 of whom became pregnant within three months of being interviewed. Folic acid supplement intake, alcohol consumption, smoking, diet, and physical activity before pregnancy were assessed. The 238 women who became pregnant within three months of the interview were only marginally more likely to comply with recommendations for those planning a pregnancy than those who did not become pregnant in this period. It was concluded that only a small proportion of women planning a pregnancy follow the recommendations for nutrition and lifestyle.

Greater publicity for the recommendations is needed, but as many pregnancies are unplanned, improved nutrition and lifestyles of women of childbearing age is also required.

Women's Health

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.

Newsletter April 2009