Endometriosis and other efforts for women′s health


  • Reynir Tómas Geirsson

At the end of the month of May, colleagues in the Nordic countries and some others from further afield gather for the fourth time to discuss endometriosis, a disease that may for many women spoil years of what should be the best time of life. We mark the Nordic congress in Turku by four contributions on endometriosis this month. On pp. 491–5 we have a Commentary from Christine Steenberg and colleagues in Oslo, Norway, on a problem that is receiving fresh attention, namely the debut of endometriosis at a young age and how this should be dealt with. The diagnosis is for a start not straightforward, because symptoms are not specific. Severe primary dysmenorrhea should be taken seriously, though, as should an additional family history of endometriosis [1]. Both have often been ignored in the past. The young girl who cannot go to school or work because of menstrual pain was given a couple of pain killers and told to just get up and go. Parents, teachers and doctors alike may have lacked knowledge and appreciation of a “hidden” disease. How views are changing in this respect is well covered in the Commentary, followed by a good discussion of what to do. Note the two tables in this article. Treatment options may be better than many realize. Early commencement of oral contraceptives must be regarded as a mainstay start-up therapy, even if research is needed to elucidate short- and long-term effects on the development of endometriosis [2]. We as gynecologists have much to contribute here to women′s health by alerting professionals and society to early endometriosis symptoms. In this we are helped by the patient associations who are our allies in this and will also join in at the Turku congress.

The link between endometriosis and a raised risk for hormone-dependent cancers later in life, not least ovarian cancer [3, 4], is another issue of women′s health which needs to be in the professional and public domain. The article by Anna-Sofia Melin and co-workers in Stockholm, Sweden (pp. 546–54), a well known group working on epidemiologic aspects of endometriosis, has from our side at AOGS been high-lighted by a press release, because we felt that this novel case-control study based on a whole population had an important message, namely that removal of endometriotic lesions has a protective effect against ovarian cancer. This knowledge is likely to affect clinical practice and the way endometriosis surgery should be conducted. The role of hormonal treatment, including oral contraception, is as yet less clear and a complex matter that calls for much more research. This is all discussed in an excellent fashion in this article, which certainly should be worth your attention.

Dietmar Haas and colleagues in Linz, Austria, compare the current two main classification systems for endometriosis (pp. 562–6). They introduced this topic earlier in the year in AOGS [5] and here they point to the value of using both systems for classifying the disease, which should benefit research in this field. Lastly on pp. 605–6 Cherif Akladios and colleagues in Strasbourg, France, pose the question whether women are more likely to get endometriosis if they are left-handed. It is hard to imagine a plausible reason for this, but curiosities are not boring.

Expenditure on health is a concern for national economics everywhere, not least in the current recession climate worldwide. Our second review article this month by Micheal Fahy and colleagues in Dublin, Ireland (pp. 508–16), deals with this and highlights that reliable information on most aspects of the cost of maternity care is needed. The exception is cesarean section, the most costly way of birth. The recommendations for action on p. 515 are noteworthy and need to be taken into account for constructing future services. This relates directly to the topic of iatrogenic late preterm delivery in Greece by Georgios Baroutis and colleagues on pp. 575–82. This is an unusually large epidemiological study from this part of the world where cesarean section rates are a major concern [6, 7], not least from a national economic perspective. Figs. 2 and 3 are astounding, not least when we think of how we in the high-resource Nordic countries manage to show better perinatal outcome indicators with less than half the section rates of southern Europe. The difference can only be due to the different way that people pay for “health”.

We feature two articles of importance for the management of endometrial cancer. First Iori Kisu and colleagues in Tokyo, Japan, show that obtaining intraoperative frozen sections to assess myometrial invasion in endometrial cancer is needed in addition to magnetic resonance imaging (pp. 525–35). MRI alone is not sufficiently reliable they suggest, although MRI is a necessary preoperative evaluation adjunct, together with hysteroscopically directed biopsy for determining the necessary extent of surgery, as Gitte Ørtoft and co-workers in Aarhus, Denmark, show on pp. 536–45. In this article there is an informative discussion about aspects of the modern handling of endometrial cancer.

Obstetricians, pediatricians and midwives have long argued over when the cord should be clamped. There is no question about what to do when the baby comes out in an asphyxiated condition, but what are the merits and disadvantages at a normal delivery or even at elective cesarean section? From the randomized study of Ola Anderson and co-workers in Halmstad, Uppsala, Helsingborg and Umeå, Sweden, one gets the impression that it may not matter so much (pp. 567–74). In obstetrics it is often good to wait a bit, so here the rule could be that there is no need to rush.

Lastly it may be right to remind the reader that there are now about 1000 days left for the world to live up to the eight Millennium Development Goals (MDGs)(www.un.org/milleniumgoals/). There has been progress during the past 4600 days since the year 2000. The UN says: “The MDGs are the most successful global anti-poverty push in history. Governments, international organizations and civil society groups around the world have helped to cut in half the world's extreme poverty rate. More girls are in school. Fewer children are dying. The world continues to fight killer diseases, such as malaria, tuberculosis and AIDS. There are 1,000 days to accelerate action on issues such as hunger, access to education, improved sanitation, maternal health and gender equality”.

Points for observance

Combining cervicovaginal IL-6 and gestational age at sampling may be of use for predicting intra-amniotic infection (pp. 517–24).

Preterm fetal death is associated with both small and large placentas relative to birthweight, but only small placentas are seen with with fetal death at term. (pp. 583–90).

Mild inflammatory reaction signs are part of the physiologic development of normal pregnancy (pp. 601–5).

Useful attendance suggestions

The 4th Nordic Endometriosis Congress (NCE2013) in Turku, Finland on 23.–25. May (www.NCE2013.fi).

The ISSHP European Congress is in Tromsö, Norway, 12.–14. June (International Society for the Study of Hypertension in Pregnancy, www.isshp.org).

The 10th congress of the European Society of Gynecology, Bruxelles, Belgium 18–21 September 2013 (www.seg2013.com).