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Endometriosis and other efforts for women′s health
Editors Message
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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”.
References
- 1
- 2
- 3
- 4, , , , , . Endometriosis as a prognostic factor for cancer survival. Int J Cancer. 2011 Aug 15;129(4):948–55.
Direct Link: - 5, , , . The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Acta Obstet Gynecol Scand. 2013 Jan;92(1):3–7.
Direct Link: - 6, , . A comparison of trends in caesarean section rates in former communist (transition) countries and other European countries. Eur J Public Health. 2012 Nov 30. doi:10.1093/eurpub/cks165.
- 7, , , , . Caesarean delivery in South Italy: women without choice. A cross sectional survey. PLoS One. 2012;7(9):e43906. doi:10.1371/journal.pone.0043906.
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).
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