BJOG Editor's Choice


The plague of niches

Subspecialisation has had numerous benefits to women's health including enhanced care to women with rare and serious conditions, improved training of clinicians, and multiple research platforms focused on niches of ignorance within the broad construct of women's lives and wellbeing. Our department at the University of North Carolina has embraced this approach ‘whole hog’, to use an NC colloquialism, and the result is seven subspecialty fellowships in maternal and fetal medicine (MFM), gynaecological oncology, reproductive endocrinology and infertility, family planning, urogynaecology, pelvic pain and reproductive epidemiology. We take great pride in these divisions, or silos, but they can confuse, frustrate and even harm patients. Consider the 37-year-old woman I recently saw who in the past 18 months had seen a reproductive endocrinologist for mild subfertility, a midwife for prenatal care and delivery, an MFM specialist for her ‘advanced maternal age’, a gynaecological oncologist for a low-grade finding on cervical cytology, a family planning consultant to get an immediate insertion of an intrauterine device postpartum, and a urogynaecologist as she had a third-degree laceration with flatus incontinence (Figure 1). Her pocketbook was depleted from her parking costs alone and I would argue that none of her ‘conditions’ were life-threatening. Readers from outside the USA can readily deduce why our healthcare system is so expensive and frustrating.

Figure 1.

Has subspecialisation gone too far?

The piecemeal approach to patient care bleeds over into research as this woman participated in three clinical trials or observational studies. None of these studies had any long-term or longitudinal follow up of her or her baby and were just as myopic as her clinical care. It is no wonder my late mother often laughed at what I claimed was medical progress.

In this issue of BJOG, we have a number of papers that have resisted the temptations of the short term and the trivial. Each struggles with the difficult challenge of putting their work into the perspective of a patient's lifetime. While imperfect, I applaud their effort to resist the easy and I believe our readers and their patients will benefit from thinking about diseases in women's health in a broader context.

Whither endometriosis and subfertility

From pubarche to menopause, endometrium can escape the uterine cavity or endometrial progenitors can be activated by cyclical rise and fall in sex steroids and produce the condition of endometriosis. Endometriosis can be debilitating, with dysmenorrhoea and pelvic pain, or asymptomatic. It is associated with subfertility, and it is not known if it causes a decline in fecundity, or is a by-product of such. If it is causal, and that is not at all clear, then medical or surgical treatment can be a logical strategy to test in subfertility management trials.

On page 1308, Harb et al. conducted a systematic review to work on that important causality question. They carried out a systematic review looking at observational studies of assisted reproduction cycles in women with and without endometriosis. They found impairment in implantation and clinical pregnancy rates in women with stage 3 and 4 disease. This does not answer the clinical question of whether treatment improves fertility, but does show that extrauterine endometrium has intrauterine effects in implantation.

Just a lightning strike?

Pre-eclampsia and eclampsia derive from the Greek word for lightning and imply a single isolated event. Every medical student quickly learns that the end-organ manifestations of toxaemia quickly reverse after delivery and delivery remains the only true treatment for this condition. But is it all over after a flash of light and some thunder? Administrative data that allow long-term follow-up of women with pre-eclampsia demonstrate an increased risk of cardiovascular disease after an index case of pre-eclampsia. Gallos et al. (page 1321) and Drost et al. (page 1333) give us hints as to why this syndrome may be much more than a pregnancy-limited condition. Gallos et al. provide a systematic review of observational studies and shows that hypertriglyceridaemia is present when pre-eclampsia is diagnosed and at mid-pregnancy before the onset of disease. The hypertriglyceridaemia is over and above that induced by pregnancy and such nutrient excess is a diagnostic component for the metabolic syndrome and a well-known risk factor for cardiovascular disease. Drost et al. take this a step further by reporting on a longitudinal cohort from a rural town in the Netherlands, Doctinchim, with 15–20-year follow-up of reproductive-age women. Women who had a hypertensive disorder during pregnancy had higher blood pressures but not more diagnoses of hypertension or higher body mass indices than women who did not. Contrary to the hypothesis from the systematic review, total cholesterol and high-density lipoprotein cholesterol were not different.

Subspecialisation not only divides our discipline by content (one could use the word space) but by time. That approach to discovery and learning has very short horizons and we need to recalibrate our projects to look at health across an individual's lifespan. This approach transcends discipline and applies to seemingly disparate conditions such as endometriosis and pre-eclampsia. Perhaps much of the mystery about their aetiology and management would be amenable to a more longitudinal approach to our research?

Childbirth and pelvic floor function

On page 1430, Chen et al. take a longitudinal approach to looking at prolapse from the third trimester to 1 year postpartum. They achieved the laudable goal of 100% follow up in 110 women having their first baby. Pelvic organ prolapse occurred before delivery, and very few cases developed de novo after delivery. This again points to the fact that pregnancy itself, rather than route of birth, may be the inciting event for long-term pelvic floor dysfunction. They overreach in trying to use these data to inform the controversy on elective abdominal delivery, but clearly demonstrate the importance of longitudinal cohort studies with rigorous methods and meticulous follow-up.

Whom should we biopsy?

I attend in our Resident Continuity Clinic once or twice a month and I am amazed by their very low threshold for endometrial biopsy. I perform far fewer in my own practice and attribute their enthusiasm to being a by-product of working in a busy gynae-oncology service and the fear of cancer that duty produces. The paper from Shapley et al. on page 1348 should pour cold water on their ardour to perform this mildly painful and invasive diagnostic test. The authors worked within seven general practices and constructed a prospective cohort of 2104 women aged 40–54 years, which is the perimenopausal epoch marked by abnormal bleeding. They found that the incidence of intermenstrual bleeding was 24% and of post-coital bleeding was 8%. Over half the symptoms spontaneously resolved within 6 months. Most pertinent to my learners in the continuity clinic, only one woman of 785 symptomatic ones had an incident malignancy during 2 years of follow-up, which was a cervical neoplasm and not endometrial. Hence, intermenstrual and postcoital bleeding are quite common, more so than reported heretofore, and have a very low positive predictive value for endometrial malignancy. Kudos to those investigators for their longitudinal approach and perhaps I can get my continuity clinic learners involved in the Twitter journal club coordinated by BJOG at #Bluejc? Electrons swirling through space and registering in phones may be a better teacher than my scowls and incredulity. Hard to admit that publically, and time will tell if any of my learners read my public confession in print.