In patients with polycystic ovary syndrome (PCOS) metabolic changes persisted and waist circumference increased over two decades of follow-up, although hormonal parameters improved, in a longitudinal study from Italy. Dr Chris Barclay, GP with an interest in O&G, Suffolk, commented on the study: 'The message I took from this paper is that although some of the manifestations of PCOS may abate with time the high risk metabolic abnormality underlying the condition (insulin resistance) does not.Women with PCOS should be viewed as a group at enhanced risk of CHD and type 2 diabetes and should be identified for preventative interventions. My first step in managing these patients is to advise a low-carbohydrate/low-glycaemic index diet to address their hyperinsulinism and insulin resistance.'

Researchers from the US have developed a risk score that could be used to quantify women’s risk of ovarian cancer and determine which patients should be offered prophylactic oophorectomy at the time of hysterectomy. A total of 1,098 women who developed invasive ovarian cancer were compared with 1,363 controls aged > 40 with no history or family history of breast or ovarian cancer. All completed a questionnaire.Several factors emerged as conferring higher risk of developing ovarian cancer. These were were: polycystic ovary syndrome or obesity, Jewish ethnicity, habitual application of talc to the genital area, dysmenorrhoea or endometriosis, less than one year’s use of oral combined contraception, no tubal ligation, no breast feeding and nulliparity. 'This study suggests that it may be possible to identify women at greater risk of future ovarian cancer who may be especially advised to have prophylactic oophorectomy,' says Dr Chris Barclay GP with an interest in O&G, Suffolk. 

Babies have a lower risk of developing iron deficiency anaemia at four months when there is a delay in clamping the umbilical cord after delivery, a study from Sweden has shown. A total of 400 term babies were randomised to early cord clamping (within 10 seconds of birth) or delayed clamping (at least three minutes after delivery). Babies were held 20 cm below the level of the perineum to aid flow of blood from the placenta to the baby before division of the cord. At four months, there were no differences in haemoglobin levels between the two groups. However, mean ferritin levels were 117 and 81 µg/L, in delayed and early clamped babies, respectively, a difference of 45%.

Regular routine check ups on women fitted with intrauterine contraceptive devices (IUD) do not appear to confer any protection against adverse events, a UK general practice-based study has found. The medical records of women registered with one practice in Rugby, Warwickshire who had had an IUD fitted between 1976 and 2005 were examined. Only women who had a device in place for at least two years with a complete set of legible records covering the time between insertion and removal or study endpoint (March 2007) were included in this retrospective analysis.

Combined oral contraceptive pills (COCPs) containing desogestrel, gestodene or drospirenone appear to confer double the risk of venous thromboembolism (VTE) compared with those containing levonorgestrel, a large population-based study in the BMJ has found. Data on all women in Denmark aged 15-49 years were identified from four national registries during the period 2001-2009. After exclusions for confounders such as malignant disease, pregnancy and coagulopathy almost 1.3 million women with more than 8 million women-years of data were analysed. Around a third had never used the COCP. A total of 4,307 thromboembolic events were recorded in this cohort of which 4,246 were included and 2,847 (67%) were deemed certain cases as anticoagulant use was also confirmed. The analysis controlled for confounders such as BMI, smoking and social class.

For healthy women with low-risk pregnancies the incidence of adverse perinatal outcomes is low in all birth settings. However, for those who are nulliparous the risk of an adverse outcome appears to be higher for births planned at home, a national cohort study has found. There was also a high intrapartum transfer rate. Over a two-year period nearly 65,000 women ‘attended by an NHS midwife during labour in the planned place of birth’ were enrolled in the Birthplace in England national prospective cohort study. Dr Chris Barclay, GP with an interest in O&G, Suffolk, reviews the study. He concludes: 'So, where is the best place to give birth? The answer appears to be that it depends on the presence of pre-existing risk factors and maternal preference. The outcomes in the midwifery units were very reassuring. However, the significantly higher figures for adverse perinatal outcomes and transfer during or just after labour from home to an obstetric unit in nulliparous cases opting for a home birth is food for thought.'

Women with polycystic ovary syndrome (PCOS) are more likely to suffer adverse pregnancy and birth outcomes, a population-based cohort study from Sweden suggests. The researchers identified women with singleton pregnancies who gave birth between 1995 and 2007, using the Swedish medical birth register. Using linkage to another national database, they established that, in this cohort, 3,787 births were to women with diagnosed PCOS and 1,191,336 were to women without the disease. Data on maternal and fetal pregnancy outcomes were collected. Comments Dr Chris Barclay: 'We know that women with PCOS are more likely to be overweight and are at greater future risk of diabetes and cardiovascular disease. The results of this study suggest that they are also more likely to have high-risk pregnancies. There are two observations I would like to make on this study. First, the numbers of women with diagnosed PCOS here were small, and this may have obscured the magnitude of its adverse effects on pregnancy. Second, nowhere in the paper were the significance of hyperinsulinism or the metabolic syndrome discussed which considering they are common and relevant characteristics of PCOS was baffling.'

Failure rates are significantly higher following hysteroscopic sterilisation (HS), in a theatre or office setting, compared with laparoscopic sterilisation (LS), a study has found. A research group from Pittsburgh reviewed the literature and collated a number of studies from which data were extracted and analysed. All studies had to have a minimum of 50 subjects with follow-up for at least 12 months. No absolute figures were presented, only percentages. Figures for successful sterilisation at the first attempt were: 99%, 86% and 85% for LS, HS in theatre and HS in the office setting at three months and 99%, 88% and 87% respectively six months post-procedure. The respective figures at 12 months were 99%, 95% and 94%. However, the method by which some patients were eventually successfully sterilised was different from the method they chose initially. Although, some women elected to have a second HS attempt, 7.0% of patients who had had HS in theatre and 5.3% of those who had had HS in an office setting went on to have a laparoscopic procedure. Overall, 5% of patients declined any further sterilisation attempts. When best and worst case data were compared the difference in success rates at 12 months showed LS to outperform HS by 0.4-10%.

Uptake of IUD insertion is greater when it is offered immediately after termination than when insertion is delayed for four to six weeks. Expulsion and bleeding were no higher in the early insertion group a study has found. Dr Chris Barclay reviews the paper, commenting, 'The care of women undergoing termination of pregnancy is incomplete unless a plan for future contraception is addressed. The copper IUD is a reasonable option; it has a low failure rate and requires no further action from the woman for it to be effective. The authors conclude that immediate insertion of a copper IUD after medical termination should be offered routinely to women. The suggestion from this paper is that diligent and proactive attention to post-termination contraception is beneficial although the trend for six-month continuation rates was lower for early IUD insertion. Careful follow-up checking for expulsion is also advisable.'

A prospective population-based case control study from New Zealand suggests that maternal sleep practices may increase stillbirth rates, but the risk was still low. The absolute risk for late stillbirth among women who fell asleep in the left lateral position was 1.96/1,000 births compared with 3.93/1,000 for those who did not.

Combined oral contraceptives containing drospirenone appear to carry a three-fold higher risk of non-fatal idiopathic venous thromboembolism (VTE) than those containing levonorgestrel, although the overall risk is still low. The study used data from the UK General Practice Research Database (GPRD) that gathers information from a large number of general practices and more than three million people in the UK, including demographic data, information about prescribed drugs, diagnoses, hospital admissions and deaths.

Loop excisions <10 mm for CIN do not raise the risk of recurrence in women aged 35 and under with high-grade disease, a study has found. A total of 1,558 women with high-grade CIN undergoing loop excision of the cervix, over a six-year period, were studied. 'The upshot is that smaller loop excisions in potentially fertile women appear safe.'

A single visit protocol based on serum progesterone measurements appears to be a safe and effective approach for triaging and managing women with pregnancy of unknown location (PUL). A total of 6,201 women with suspected early pregnancy complications attended King's College Hospital, London over the 15-month study period. There were 676 (10.9%) with PUL, defined as a positive pregnancy test but with no evidence of a gestation sac in utero or ectopic on ultrasound scanning. Of these 252 were found to have a progesterone level <10 nmol/L. All but one of these women were treated as outpatients and were not invited for further investigation.

An observational study from Canada has shown that a decline in the use of HRT over the past decade was followed by a reduction in the incidence of breast cancer. Data on HRT prescriptions dispensed for women aged 50-69, during the years 2001-2006, was collated from a national registry. Information about current HRT use was obtained by telephone from a sample of 1,200 women in this age group already enrolled in the National Population Health Survey. Subjects were asked ‘in the past month, did you take hormones for menopause or ageing symptoms?' Those who answered affirmatively were asked about the type of formulation used. 'It would seem logical that prolonging a woman's exposure to sex hormones would increase risk (breast cancer is slightly more common in women with early menarch and late menopause). However, the data are observations of association only, and are not controlled for other risk factors for breast cancer such as parity and alcohol intake. The absolute risk of breast cancer to an individual user of HRT is small (and smaller still in oestrogen-only formulation users). The potential benefits need to be weighed up against the risks for each individual patient.'

 Treating periodontal infections during pregnancy is unlikely to reduce the risk of preterm birth. A trial of dental hygiene treatment was conducted among pregnant women in Pennsylvania. The initial phase was the development of standard criteria to determine if periodontal disease was present. This involved measurement of gingival pocket depth and connective tissue attachment to teeth. In the second phase, 322 pregnant women with periodontal disease were given oral hygiene instruction and free supplies of floss, brushes and toothpaste. Half were randomised to have dental scaling and root planing as well. No significant difference in the incidence of preterm births was seen between the two groups; 52.4% in the control group and 45.6% in the intervention group. The third phase of the study looked at those women who had the scaling and root planing. All received treatment before 20 weeks gestation and an assessment of the success or otherwise of treatment 20 weeks later. Success equated to improvement in periodontal disease criteria or being no worse. A total of 49 successful and 111 unsuccessful cases were identified. The numbers of preterm deliveries were 4 and 69 respectively, indicating a strong association between periodontal disease progression in pregnancy and preterm delivery. There was a significant relationship between successful periodontal treatment and full-term birth.

The setting up of a paediatric and adolescent gynaecology (PAG) service in a DGH has enabled new pathways of care and the development of best practice, a study in the BJOG concludes. The report from this PAG service makes a case for special training for gynaecologists with an interest in paediatric gynaecology and that girls are seen in a paediatric rather than an adult clinic setting. A total of 800 girls were referred to the PAG service in Kettering General Hospital over a 15-year period between 1994 and 2009. The peak age for referral was bimodal at 4 and 15 years of age. 'Not surprisingly menorrhagia and dysmenorrhoea were common comprising 13% of all referrals with a peak age of 14 years. Only 17% had received any treatment from the GP before referral. Treatments given subsequently included the combined pill, depot provera, mefenamic and tranexamic acid as well as HRT and an IUS. And 5% required diagnostic laparoscopy for possible endometriosis. Other problems included amenorrhoea (primary and secondary), urinary symptoms and incontinence and suspected sexual abuse. This latter category comprised just 3% of the total with an age range of 3 months to 15 years. Sub-specialisation is the order of the day in gynaecology and other hospital specialties. The authors make a strong case that each unit have a consultant with a particular interest in paediatric gynaecology and multidisciplinary links for example with urology, endocrinology and dermatology services.'

Amniotic fluid embolism (AFE) although rare carries a high risk of severe morbidity and death, a study from Australia has confirmed. Maternity data were assessed over seven years in a cohort of 606,393 deliveries in New South Wales. Twenty cases of AFE were identified giving an incidence of 3.3 per 100,000 deliveries. All were in singleton pregnancies, 79% were in multiparous women. Seven women died; a case fatality rate of 35%. In the six women who died in hospital the perinatal death rate (stillbirths + neonatal deaths) was 50%. Perinatal mortality where the mother survived was 23%. 'I found this study of interest not just because it served as a useful reminder of the condition but also its demographic and delivery associations. Survival appeared strongly linked to rapid high-tech intensivist intervention.'

A diet with a low glycaemic index (GI) can improve insulin sensitivity in women with polycystic ovary syndrome (PCOS), a study from Australia has found. A total of 96 overweight or obese women with PCOS were randomised to a low-fat, low-GI diet or a nutritionally similar, but average GI, conventional healthy diet. They were followed up for 12 months or until they had reduced their weight by 7%. The women received dietetic support, menus and shopping lists, and free provision of certain carbohydrates. 'It seems clear that low GI nutrition can significantly improve insulin sensitivity. However, even with regular dietetic input and free food the drop out rate was significant in this study. Translating the science into an effective clinical intervention remains a problem.'

Low-dose transdermal oestrogen patches do not appear to raise the risk of stroke. However, high-dose patches, oral HRT using oestrogen alone or combined with a progestagen, are associated with an increased risk. A total of 15,710 cases of stroke were identified, from a cohort of nearly 900,000 women aged 50-79, on the General Practice Research Database; giving an incidence of 2.85 per 1,000 woman-years. The average age at stroke was 70 years. Four matched controls were selected for each case.

Pregnant women should be counselled and fully informed before undergoing examination for soft markers on routine mid-trimester scans, a study from Toronto has concluded. 'Mid-trimester ultrasound examination is a form of screening and all women agreeing to it should be counselled before proceeding. All clinical screening can potentially cause harm as well as benefit. In the case of soft marker screening the harm includes false-positive results and screening women who if asked would have declined. In my opinion, women who do not want Down's syndrome screening should not have soft markers assessed without their informed consent.'

A large study conducted by the RCGP, amassing more than one million woman-years of data, has provided reassurance on the safety of the combined oral contraceptive pill (COCP). The study collected long-term data prospectively on more than 28,000 COCP users and a further 17,000 never-users. 'The authors controlled for age, parity, smoking and social class but did not have data on obesity, a variable significantly linked to cancer and mortality risk. Nevertheless this massive, well conducted study provides reassurance that if anything the COCP appears to have significant non-contraceptive health benefits, at least during and shortly after taking it.'

Adolescent girls who fail to respond to medical management of menstrual problems may have underlying pathology such as endometriosis. A total of 1,051 Australian high school students aged 15-19, average 16 years 10 months, completed a detailed menstrual questionnaire. Mean age at menarche was 12 years 9 months. In 15.5% menarche had occurred at or below the age of 11 and in 23.4% after the age of 13. Almost two thirds currently reported a regular cycle with a mean duration of menstruation of 5.9 days. 'It is estimated that 10% of teenage girls have endometriosis. Despite this it takes on average 12 years for the diagnosis to be made if symptoms develop before the age of 20. But what distinguishes young women who may have endometriosis from those who do not? The majority of girls had mildly painful periods that were managed with simple analgesics and experienced little interference with activities. However, around a quarter experienced moderate or severe pain, multiple menstrual symptoms and significant interference with life activities. It is among these young women, many of whom will present to their GP because of their periods, that the possibility of endometriosis should be considered, especially in those with atypical menstrual symptoms and who respond poorly to analgesics.'

Adolescent girls with learning difficulties are more likely than average to have menstrual problems. This relates in part to the use of neuroleptic and antiepileptic drugs. Obesity and thyroid dysfunction may also be relevant. A case series from Cheltenham suggests that the levonorgestrel intrauterine system (LNG IUS) is a useful option for those patients and for those with medical disorders or physical disability. Over a ten-year period 14 young women aged 11-21 years with medical, physical or learning disabilities were referred by their GP or a consultant. All had menstrual problems that had resisted standard therapies: antifibrinolytics, NSAIDs, and where appropriate the combined oral contraceptive pill or contraceptive patch. The disabilities included previous CVA, diabetes, epilepsy, various congenital causes of learning difficulty and behavioural problems. 'The LNG IUS is now a first-line therapy for menorrhagia and should be considered in all women before proceeding to hysterectomy. Its use in teenagers with menstrual problems or indeed those requiring contraception is less common. This is, however, an example of usual practice not having kept up with medical progress. The IUS can be fitted in nulliparous women and it provides excellent long-term contraception as well as being remarkably effective in the treatment of menorrhagia. '