Obstetrics and Gynaecology Forum - Volume 19, Issue 2, May 2009

Prior to the publication of the prematurely terminated Estrogen and Progestin (EP) arm of the WHI trial in 2002, hormone therapy (HT) in postmenopausal women was not very complicated. Available evidence from observational studies suggested that the majority of postmenopausal women would benefit from what was then termed hormone replacement therapy (HRT). Besides relief of menopausal symptoms and prevention of osteoporosis, it was widely believed that postmenopausal women using HRT also enjoyed significant protection against coronary heart disease (CHD); hence HRT was easily prescribed without much deliberation. The first WHI study results published in 2002 failed to show this benefit in the population it studied. These findings as well as the increased relative risk for the development of breast cancer received extensive coverage in the media, and it wasn't long before HRT was regarded as being dangerous. The HERS II study was published in the same month and concluded that HT should not be used to reduce risk for CHD events in women with CHD.

The subject of mode of delivery of twin pregnancies has been the topic of several journal publications. This debate was rekindled in a recent editorial where the question was raised whether all twins should be delivered by caesarean section. Most of this debate concerned the neonatal outcome of the second born twin. The second twin is at a greater risk of hypoxia because complications such as malpresentation, the longer second stage, cord prolapse and abruptio placentae are more likely to occur at delivery of the second twin. This has prompted several countries and academic centres to examine their data on neonatal outcome and mode of delivery in twin gestations.

Preterm Labour (PTL) and Preterm Premature Rupture of Membranes (PPROM), both defined as occurring spontaneously before 37 completed weeks of pregnancy, have long been recognized as the major contributor to perinatal mortality and morbidity. The outcome for the baby deteriorates proportionately the earlier the incident occurs. It is estimated that spontaneous preterm birth is responsible for 21.8% of perinatal deaths or 6346 babies per year in South Africa. Preterm birth is less common in first world countries (±12% of deliveries) but in spite of intensive research the figures continue to increase. A disproportionate amount of the costs incurred in managing neonates are caused by preterm delivery. Approximately 30% of preterm deliveries are indicated - the most common reasons being pre-eclampsia, fetal distress, intra-uterine growth restriction and obstetric haemorrhage. This category continues to increase because of the increased in multiple births from assisted reproductive treatment, changes in obstetric management between 34-37 weeks gestation and induction of labour in very preterm infants coupled with the willingness to resuscitate extremely low birth weight infants. Of the remaining two thirds of preterm deliveries approximately 60% are associated with infection and this group is divided equally between PTL and PPROM.

Cervical cytology is a well-established screening tool for cervical neoplasia. The introduction of the Papanicolaou test in the 1950's has led to sustained reductions in both the incidence and mortality from cervical cancer in developed countries. Cervical cancer incidence rates in the United States have dropped from 14.8 / 100 000 in 1975 to 6.7 in 2005.

When there is a medical or surgical indication for a hysterectomy apart from endometriosis the following discussion is not really relevant. The question deals with the role of hysterectomy purely for the management of endometriosis. Women, who have pelvic pain due to endometriosis that is unresponsive to conventional therapy that can include surgery or medication, are often advised to have a hysterectomy with or without a BSO. Age, gravidity and parity must be carefully considered when deciding on a hysterectomy and especially more so when a decision has to be taken surrounding a BSO.

The true incidence of pelvic organ prolapse (POP) is difficult to determine, however, it is a common condition reported to affect 50% of parous women over 50 years of age. In their widely cited study, Olsen et al found a lifetime risk of 11% (by age 80 years) for women to undergo surgery for POP and urinary incontinence. The risk of recurrent POP after surgery is reported to be between 10-30%. Although non-life threatening, POP is an embarrassing condition that has been shown to negatively impact on various quality of life domains. Population modeling studies have projected a population of 9 billion by 2040 and also an increase in demand for services to care for female pelvic floor disorders. Currently non-surgical treatment modalities include expectant management, pelvic floor exercises and the use of support devices i.e. vaginal pessaries. Vaginal support devices date back to at least 1550 BC, and have remained the mainstay of treatment for POP until recent advances in pelvic floor reconstructive surgery.

More than 40 genital types of HPV have been identified, of which 15 are known to be oncogenic. High risk HPV types cause all cervical cancers and true cervical pre cancer lesions, including cervical intra epithelial neoplasie III. HPV types 16 and 18 are the most common oncogenic HPV types associated with cervical cancer. HPV 16 accounts for nearly 60% of all cervical cancers, and HPV 18 accounts for another 10-20% of cervical cancers. The second most common histological type of cervical cancer, adenocarcinoma of the cervix, is becoming increasingly common in the USA. The rate of association between HPV 16 and 18 and cervical adenocarcinoma is similar, and in some populations the rate of HPV 18 exceeds that of HPV 16. HPV is also implicated in 30% of oropharyngeal cancer, 45-95% of anal cancer, 60 to 65% of vaginal cancer and 40 to 60% of vulvar cancer.

Novartis South Africa (Pty) Ltd is proud to announce the registration of Aclasta (zoledronic acid 5 mg) for the once yearly treatment of postmenopausal osteoporosis.