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Authors

  • Athol Kent


Contraception in the USA

Americans continue to grapple with the anomalies of their healthcare system. With the Affordable Care Act in sight, the question of contraception for all is high on the priority list. The latest data (for 2006) still show that half of all pregnancies in the USA are unplanned but the use of emergency contraception remains low and some methods, for example the intrauterine device (IUD) remain underused (Mitka JAMA 2012;307:2473–4).

Research shows that a copper-containing IUD inserted within 5 or even 10 days of unprotected intercourse has a failure rate of <1 per 1000, which is 10–20 times better than oral medications such as ulipristal acetate or levonorgestrel (Cleland et al. Hum Reprod 2012;27:1994–2000). It seems however that IUDs in the USA remain unfashionable, although attitudes may be changing with use rates rising from <1% in 1995 to 5% in 2008. Incidentally, the rate of use in France is 24%.

The reasons for low uptake are not to do with efficacy but with education and initial cost. So it may be that the more healthcare matters are talked about, the greater the openness that might be engendered, and one wonders how well the growing influence of the electronic social media will inform the next generation. Meldrum has recently published an intriguing history of the contraceptive choices North American women make, highlighting how they interact ‘with feminism, concerns about pharmaceutical marketing, and the rising consciousness of women about their own health’ (Meldrum. Women making contraceptive choices in 20th-century America, Lancet 2012;380:102–3).

Intellectual dishonesty

As students we were taught to think rigorously about problems; to apply our minds to the evidence provided by the science of our profession; to bring ethical principles to our judgements about our management of patients to ensure that, on balance, we do more good than harm. Any intervention has to be weighed from both the public health and the private points of view, from the theoretical to the pragmatic, from the cost-effective to the affordable and take into account the patient’s emotional and social circumstances. So why do these principles desert us when it comes to screening?

Ovarian cancer screening in low-risk women

Three-quarters of women with ovarian cancer present late because of the lack of symptoms and the overall 5-year survival rate is at best one-third, which makes it the fifth leading cause of malignant deaths in women. This positions it as a high priority for early diagnosis but our present screening methods of ultrasound combined with CA125 are neither sensitive nor specific enough to meet the criteria of a valid screening tool.

The accepted conditions for effective screening include an understanding of the natural history of the disease—which we lack, probably because of the heterogeneity of ovarian lesions—on top of which the latest data demonstrate that screening does more harm than good (Buys et al. JAMA 2011;305:2295–303). This research showed that more screened women had oophorectomies than the non-screened controls, but most of them were negative for cancer and nevertheless carried significant morbidity rates. More screened women died than controls. The UK Collaboration Trial of Ovarian Cancer Screening pilot study was not convincing with fewer than 1% of the trial participants having surgery and 70% of those operated on not having cancer (Menon et al. Lancet Oncol 2009;10:327–40). A Japanese study also showed that a large number of laparotomies are needed to establish the correct diagnosis and moreover early detection did not lead to lives being saved (Kobayashi et al. Int J Gyn Cancer 2008;18:414–20).

Now the influential US Preventive Services Task Force has confirmed its previous position, saying that ovarian cancer screening increases harm while there is fair evidence that it has no significant effect on mortality. If a low-risk woman enquires about routine ovarian cancer screening we have to tell her that on balance it is a bad idea as the evidence shows that it does more harm than good.

Prostate cancer screening with prostate-specific antigen in low-risk men

The same authority in America that pronounced on ovarian screening, the US Preventive Services Task Force, in May this year concluded that prostatic-specific antigen screening in low-risk men was associated with a very small reduction in mortality while resulting in considerable overdiagnosis and overtreatment, giving rise to potential harms including pain, fever, bleeding and infection from prostate biopsy as well as the possibility of erectile dysfunction, incontinence and bowel dysfunction following surgery. Put simply, a test that its inventor never intended as a screening tool does more harm than good (Lancet 2012;379:2024).

Screening programmes should be just as rigorously tested as any intervention. Norway is currently considering using new methodology (‘comparative effectiveness research’) to re-evaluate existing screening programmes (Bretthauer and Hoff BMJ 2012;344:e2864).

Bones and age

The world’s population is aging, with the very old constituting the fastest growing group. With mean life expectancy over 80 years in developed countries, conditions affecting the elderly are not only of increasing importance clinically, but are also socially and economically significant.

Osteopenia and osteoporosis were once considered inevitable and untreatable conditions, taking a vast toll in terms of cost and quality of life in senior citizens. It is estimated that a woman today has a 50:50 lifetime chance of a fracture as a result of bone fragility. Vertebral fractures cause back pain and limit mobility and function, while hip fractures carry significant mortality rates. After a year, half of survivors have not regained their previous level of independence. The present and predicted costs have not escaped the attention of the pharmaceutical companies, with one in seven postmenopausal US women currently receiving a prescription for a bone resorption prevention medication. These scripts are written by family physicians and gynaecologists as well as by orthopaedic surgeons and geriatricians, with menopausal hormone therapy an important domain of attention.

Although bone mineral density (BMD) accounts for half of the strength of bone, its measurement does indicate the likelihood of fracture, with the risk doubling for each standard deviation below the mean (the reference standard being that of a woman in her 20s). The BMD is measured by dual energy X-ray absorptiometry of the upper femur and is called the T-score. A score of −1 to −2.5 standard deviations is osteopenia whereas a score of less than −2.5 is designated osteoporosis. Apart from BMD scores there are other features that reasonably accurately predict future fracture possibilities, like age, low body mass index, personal or family fracture history, smoking and alcohol intake and comorbid conditions. These combined feature constitute the FRAX score which, with or without radiological measurements, can be used as a total to diagnose and start treating osteopenia or osteoporosis (http://www.shef.ac.uk/FRAX).

Although no one would argue with treating osteoporosis, one could also make a case for treating osteopenia or any degree of low bone mass, because half of all fragility fractures occur in people not yet fulfilling the criteria for the diagnosis of osteoporosis (Davey SAMJ 2012;102:285–8). Alendronate and strontium ranelate have both proved efficacious in reducing fracture risks in people with osteopenia. Advanced age should not be seen as a contraindication to initiating medication especially if a person sustains a fragility fracture.

A major debate is in progress in the USA about the duration of bisphosphonate treatment. There is no doubt about their use over 3–5 years as all the studies show slowed bone resorption and fewer fractures, but data are lacking about ongoing maintenance therapy with expense and adverse effects being areas of concern. Influential groups (Whitaker et al. NEJM 2012;366:2048–51; Black et al. NEJM 2012;366:2051–3) offer conservative conclusions, suggesting that therapy should only continue beyond 5 years in those with scores below −2.5, in other words in people with osteoporosis not those with osteopenia. They do concede that the evidence could change soon and they refer to alendronate and zolendronic acid only.

As we and those around us age, these issues will increase in importance with prevention becoming the most significant watchword.

Music to a woman’s ears

Waiting for a caesarean section is a stressful time for a woman. Although she may be well prepared for an elective operation, the sterile surroundings, separation from loved ones, strangers in uniform and loss of control of her environment may provoke anxiety in any woman awaiting an abdominal delivery. Anxiolytics have potential adverse effects so something soothing, like listening to music, may be a good idea.

Given rising caesarean section rates and the body of evidence in favour of the therapeutic potential of music in clinical settings, Kushnir et al. from Israel (Birth 2012;39:121–7) tried out the effects of listening to classical and local tunes for 40 minutes while women waited for theatre. They measured the woman’s emotional profile using a questionnaire and her vital signs were monitored preoperatively by a nurse. Control women were cared for similarly but without the music.

The differences were clear, with those listening to music increasing their positive feelings and decreasing their negative emotions compared with the control women who reported the opposite effects. Objectively the music listeners had reduced systolic blood pressure while the controls had raised diastolic pressure and increased respiratory rates. The experimenters suggest that this may be an inexpensive and non-obtrusive coping strategy for the ever-increasing numbers of women destined to undergo an elective caesarean section.

Stroke and myocardial infarction risks with oral contraceptives

There is a recognised increase in the risk of venous thromboembolism in users of oral contraceptives but what about arterial thrombosis? Arterial events, be they cerebral or myocardial, are more serious than their venous equivalents but fortunately rarer.

In a Danish study, the incidence of thrombotic strokes in women of reproductive years was 20 per 100 000 person years and of myocardial infarctions was 10 per 100 000 years (Lidegaard et al. NEJM 2012;366:2257–66). If women used low-dose pills (20 μg ethinyl estradiol) then the risk was significantly increased by a factor of 0.9–1.7 (depending on the progestogen with which it was teamed, although the statistical significance of the differential effects between progestogens was low because of small numbers in some categories) and if they used the higher dose pills (30–40 μg) then the risk factor increased by 1.3–2.3.

These absolute risks are small and the pills are agreed to be safe enough even without balancing their use against a single pregnancy or invoking their noncontraceptive advantages. Oral contraceptives are continuing to give women a positive choice with very few negative consequences (Petitti NEJM 2012;366:2316–8).

Footnotes

  1. These snippets are extracts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at atholkent@mweb.co.za or visit the website http://www.jassonline.com.

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