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What’s new in the other journals?

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  2. What’s new in the other journals?

Estrogens only and breast cancer

Part of the Women’s Health Initiative study of hormonal replacement therapy in the late 1990s included a group of hysterectomised women who received estrogen alone. Over 10 000 postmenopausal women were randomised to 0.625 mg of conjugated equine estrogen (CEE) daily or placebo over a period of 7 years before the trial was stopped because of an increase in stroke incidence without cardiovascular benefit.

Unlike the main study of combined progesterone and CEE in women with an intact uterus, the incidence of breast cancer in those receiving CEE alone decreased modestly with a hazard ratio of 0.80. However, this reduction has to be balanced against an increase of abnormal mammograms in the CEE-alone group, especially in the first year of follow up. The cumulative percentages of women requiring follow up for mammogram abnormalities were 36% for CEE-alone recipients and 28% for those on the placebo.

This study had the same flaws as the larger combined progesterone and CEE research, with most of the women being more than 60 years old on recruitment and being overweight, but it does raise interesting reflections that estrogen alone does not increase breast cancer risk. Would women in their 50s with a progesterone-releasing intrauterine system be able to use estrogen alone with the same protection from breast cancer? (Stefanick et al. JAMA 2006;295:1647–57).

Ultimate sex discrimination

There are more boys than girls born in India. The discrepancy is becoming more marked with every census and is greater in urban than rural areas and among higher socio-economic groups. It is not a natural process as there are more male than female stillbirths, and infant mortality ratios are equal.

The situation is even more apparent in households where the first born is a girl—the next child is much more likely to be a boy rather than another girl. In other words, the sex of the existing child or children affects the sex of the next born.

Jha et al. (Lancet 2006;367:211–8) traced these trends by conducting interviews in more than one million households. They postulate that prenatal sex testing with abortion of female fetuses is the most likely explanation which fits with India’s common ideology. Although illegal and officially condemned (Sheth, p. 135–6), the practice of ultrasonic or amniocentesis sex determination is widespread, and it is calculated that in India alone, 10 million female fetuses have been aborted in the past two decades. China is also suspected of having a similarly discriminatory attitude, and the world figure of ‘missing presumed dead’ female babies is estimated at 100 million.

Fibroid embolisation outcomes

The long-term outcomes of fibroid embolisation look promising. The FIBROID Registry in the USA is a voluntary multicentre database that chronicles the results of fibroid embolisation. There are records of more than 2000 women, and they have a unique symptom score method that allows quality-of-life measurements to be made and compared prospectively.

The results are available for the first year after embolisation, and 95% of women had significantly improved symptoms and quality-of-life scores. Only 3% underwent hysterectomy within a year of treatment. The results are remarkable, with the best outcomes being achieved when the fibroids were small, submucosal and presented with heavy menstrual loss (Spies et al. Obstet Gynecol 2005;106:1309–18).

Herbs for menopausal symptoms

Most herbal remedies for menopausal symptoms give underwhelming results—in fact, most research shows that they are no better than placebo. There is always a placebo effect in these trials, so any claims at improvements must show a reduction in symptoms well below possible ‘suggestion or Hawthorne’ effects.

At last, one such study has appeared (Uebelhack et al. Obstet Gynecol 2006;107:247–55) from Germany using black cohosh and St John’s wort. Black cohosh extract in the dosage of 1 mg triterpene glycoside, the active ingredient, is said to relieve symptoms of hot flushes, night sweats and sleep disturbances without exerting estrogenic effects. St John’s wort has proved effective in the treatment of depression and mood disorders at a dose of 0.25 mg hypericine, so the combination of the two herbs was tested against placebo in the hope of relieving menopausal physiological and psychological symptoms without the adverse effects of estrogens or selective serotonin reuptake inhibitors.

Over a 16-week trial period, the women’s menopause rating scores were reduced by 50% in the active ingredient group and by 20% in the placebo group. In the depression rating scale, treatment resulted in a 40% reduction in symptoms, with a 12% placebo effect. The authors claim that the relatively low placebo effect was due to a single investigator being employed who did not accentuate the psychotherapeutic approach.

The adverse effects were minimal, and it appears that the combination of a fixed dose of black cohosh and St John’s wort has a place in the management of climacteric complaints with a pronounced psychological component.

UK statistics of obstetrics and gynaecology popularity

In the UK, the popularity of our specialty is falling fast. Ten years ago, 5% of all graduates wanted to specialise in obstetrics and gynaecology (O&G), but this dropped to 3% in 2002 and is now estimated at 2%. This is way below the numbers required to maintain staffing levels, especially with consultants becoming increasingly required in labour wards.

Long hours and the exercising of ‘patients’ rights’ in declining students’ presence are noted by the Royal College as disincentives to choosing O&G. Foreign doctors are being looked to as numbers dwindle (Brettingham BMJ 2006;332:323).

Over-assisted reproduction?

Two percent of babies born in Europe are the result of assisted reproduction. This has helped countries of the European Union raise their birth rates, but these are still nowhere near population replacement levels (Int J Andr 2006;29:12–16).

Surely, one of the most bizarre stories about assisted reproduction must be that of Mrs Z from Russia, reported by the appropriately named Mr Leidig in the BMJ (2006;332:627). She is a 55-year-old headmistress whose son was dying of cancer, so she persuaded doctors to freeze some of his semen before treatment was started. This was carried out, and 2 years after his eventual demise, she requested his sperm be used to fertilise a donor egg and be implanted into a surrogate mother.

The child, Mrs Z’s grandson, was born alive and well, but the Russian authorities say that she is too old to adopt him. The situation is further complicated by the fact that the sperm donor died 2 years ago and cannot be legally registered as the father. Since the oocyte was donated, the baby does not have a mother either, and since he has no parents, he does not officially exist. The registry office wants to take him away from Mrs Z and place him in an orphanage. The case is going to court.

Footnotes
  1. These snippets are extracts from a monthly service called the Journal Article Summary Service (JASS). JASS summarises clinically important O&G articles published the preceding month in the world literature. If you would like to receive details of how to subscribe, please email the editor Athol Kent at atholkent@mweb.co.za or visit the website www.jassonline.com for more information.