Abstract
Women who have undergone ritual genital mutilation are more likely to suffer a variety of negative obstetric outcomes and their infants have an up to 55% increased risk of stillbirth or early neonatal death.
A WHO study published recently in the Lancet on female genital mutilation (FGM), also known as female circumcision, has demonstrated that women who have undergone mutilation of their external genitalia are more likely to suffer adverse obstetric and perinatal outcomes.
FGM is practised to some extent in 28 countries worldwide, predominantly in sub-Saharan Africa. It is largely a cultural, rather than religious, practice that is thought to ensure female chastity and fidelity.
An estimated 100 million women have undergone some form of genital mutilation, usually at a young age and often in unsanitary conditions, without anesthetic.
“This is a collaborative study conducted in Africa, with African researchers, and provides evidence of great importance to those communities where FGM is practised. It shows clearly its harmful effects on reproductive outcome, both for women and their infants,” stated Emily Banks and colleagues.
Previous studies have suggested an association between FGM and adverse obstetric outcomes, but these studies have been small and methodologically flawed. In this study, a total of 28,000 pregnant women from African countries where FGM is practised were followed during and after delivery. The women were assessed prior to delivery to determine whether they had undergone FGM and to what extent.
FGM is classified into three types. Type I involves removal of the prepuce (clitoral hood), sometimes with excision of some or all of the clitoris, while type II involves removal of the clitoris with excision of all or part of the labia minora. Type III, also known as infibulation, is the most drastic and involves removal of all or part of the external genitalia and narrowing of the vaginal opening.
The investigators found that any form of FGM had a negative impact on both the mother and baby, although more severe forms of FGM were associated with a greater risk of complications. Those with FGM type III were 31% more likely to require a cesarean section, 69% more likely to suffer postpartum hemorrhage, 98% more likely to have an extended hospital stay, and the risk of their baby being stillborn or dying soon after delivery was increased by 55%.
Even those with FGM type I were significantly more likely to suffer from these adverse outcomes, including a 15% increased risk of stillbirth or early neonatal death.
The authors concluded that “adverse obstetric and perinatal outcomes can…be added to the known harmful immediate and long-term effects of FGM.”
In a related editorial, N Eke and KEO Nkanginieme, of the University of Port Hartcourt (Nigeria), expressed their hope “that awareness of these outcomes will hasten the eradication of the practice.”
Source: WHO study group on female genital mutilation and obstetric outcome: Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 367, 1835–1841 (2006).
Testosterone patch may help androgen-deficient women
Women with low testosterone levels may benefit from testosterone administered via a skin patch, according to researchers from Massachusetts General Hospital (MA, USA).
A total of 51 premenopausal women with androgen deficiency due to problems in the pituitary gland were randomly assigned to receive either two 150 μg testosterone patches or two placebo patches twice weekly for 12 months.
Testosterone levels increased to within the normal range in women treated with transdermal testosterone. The women receiving active treatment also experienced improvements in bone mass, fat-free mass, mood, sexual function and overall quality of life.
“This is the first randomized, double-blind, placebo-controlled study to show a positive effect of testosterone on bone density, body composition and neurobehavioral function in women with severe androgen deficiency due to hypopituitarism,” concluded the authors. “Further studies will be needed to determine long-term efficacy and safety of such a replacement strategy.”
Source: Miller KK, Biller BM, Beauregard C et al.: Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study. J. Clin. Endocrinol. Metab. 91(5), 1683–1690 (2006).
in brief…
Bonnick S, Saag KG, Kiel DP et al.: J. Clin. Endocrinol. Metab. (2006) (Epub ahead of print).
Reports the results of a 1-year extension of the randomized, controlled Fosamax® Actonel® Comparison Trial (FACT). The extension was designed to compare changes in bone mineral density (BMD), bone turnover and gastrointestinal tolerability over 2 years of treatment. A total of 833 of the 1053 women who took part in the original 1-year FACT study entered the extension, remaining on either weekly alendronate 70 mg or risedronate 35 mg. The patients receiving alendronate had greater gains in BMD and greater reductions in bone turnover after 2 years than those receiving risendronate. There was no difference in gastrointestinal tolerabilty.
Loganathan RS, Stover DE, Shi W, Venkatraman E: Chest 129(5), 1305–1312 (2006).
Suggests that women with lung cancer are less likely to present with chronic obstructive pulmonary disease (COPD) than men. Of 151 men and 143 women recently diagnosed with lung cancer, women were significantly more likely to present with normal results on pulmonary function tests (PFTs). This suggests that stratification of high-risk patients based on PFTs may not be valid in female patients. Physicians should bear this in mind and keep a high index of suscpicion for lung cancer, even in women with no symptoms of COPD.
Owen JR, Ashton A, Bliss JM et al.: Lancet Oncol. 7(6), 467–471 (2006).
Demonstrates that fewer, more concentrated doses of radiation are equally effective in preventing breast cancer recurrence after surgery. The investigators assigned 1410 women with early stage breast cancer to either 50 Gy radiotherapy given in 25 fractions, 39 Gy given in 13 fractions, or 42.9 Gy given in 13 fractions. All regimens were carried out over 5 weeks. The risk of relapse after 10 years was equivalent between the different regimens.
Viagra® effective for antidepressant-induced sexual dysfunction in women
One of the side effects of selective serotonin reuptake inhibitors (SSRIs), a commonly used class of antidepressants, is sexual dysfunction. These sexual side effects might cause patients to stop their medication, with potentially serious consequences.
H George Nurnberg and colleagues have previously shown that men suffering antidepressant-related sexual dysfunction can be successfully treated with sildenafil citrate (Viagra®, Pfizer).
Dr Nurnberg's team have now conducted a study assessing the effect of sildenafil in women with antidepressant-related sexual dysfunction. This was a logical progression since, as Dr Nurnberg points out, “twice as many women have depression as men and three times as many women are on antidepressants.”
In the study, 100 women in remission from major depression who were suffering from SSRI-related sexual dysfunction were randomized to receive sildenafil or placebo for 8 weeks, followed by an 8-week open-label phase.
Based on the Clinical Global Impression of Change – Sexual Function, 69% of women receiving sildenafil, compared with only 29% of those receiving placebo, showed improvement in their sexual function.
“My message to physicians prescribing antidepressants is to tell their patients not to stop these drugs if sexual side effects occur,” emphasized Dr Nurnberg. “Instead, they should encourage the patient to discuss these effects” as they can often be treated without discontinuing their medication.
Source: American Urological Association (AUA)'s Annual Meeting. Atlanta, GA, USA, 20–25 May (2006). Abstract available at: www.aua2006.org
In vitro fertilization may increase risk of pregnancy complication
Women who have conceived using in vitro fertilization (IVF) appear to have up to a six-times higher risk of developing placenta previa, a condition in which the placenta blocks the cervix, preventing the baby from being born naturally. This often leads to vaginal bleeding and delivery by cesarean section.
A total of 850,000 singleton pregnancies recorded in the Norwegian Medical Birth Registry were analyzed, of which approximately 7600 were the result of IVF. Of these, 1349 women were identified who had conceived both naturally and by IVF, and the increased risk of placenta previa was present regardless of whether the IVF pregnancy was before or after a natural pregnancy.
However, the authors stress that “although the risk of placenta previa is considerably higher with assisted reproduction it is still quite rare,” and feel that these data should not put women off IVF.
Instead, the authors suggest that doctors be aware of the increased risk and that fertility clinics record the position of the embryo at implantation. Many IVF practitioners prefer to place embryos lower down in the uterus, as this is thought to improve pregnancy rates, and the authors suspect this may be behind the increased risk of the disorder.
Source: Romundstad LB, Romundstad PR, Sunde A, During VV, Skjaerven R, Vatten LJ: Increased risk of placenta previa in pregnancies following IVF/ICSI; a comparison of ART and non-ART pregnancies in the same mother. Hum. Reprod. (2006) (Epub ahead of print).
Women using long-term estrogen replacement therapy at greater risk of breast cancer
While the Women's Health Initiative demonstrated a link between 7-year estrogen–progestin replacement therapy and breast cancer in postmenopausal women, it failed to show such an association for estrogen alone over this period.
However, a new study by researchers at the Brigham and Women's Hospital (MA, USA) has demonstrated that longer-term therapy with estrogen does increase the risk of breast cancer.
“Estrogen only causes cancer after prolonged exposure,” explained lead author Wendy Y Chen.
The investigators examined data on 28,835 women enrolled in the Nurses Health Study, of whom 934 developed invasive breast cancer. The study concluded that women receiving estrogen for 15 years or more were at increased risk of breast cancer. Those who had been receiving estrogen therapy for 20 years or more were 42% more likely to develop breast cancer. As might be expected, this risk was greatest for hormone receptor-positive tumours.
Long-term estrogen therapy can increase the risk of breast cancer in postmenopausal women, according to a study published recently in the Archives of Internal Medicine
Dr Chen suggests that women need to balance the risks and benefits of long-term estrogen therapy: “for women who use estrogen alone, and have been on it for more than 10 years, they would want to consider how much longer they want to remain on estrogen.” She added, “if you are taking it for less than 15 years, we haven't seen a significant increase in risk, but after 15 years, women should speak to their physician about the benefits of being on estrogen and how would that be weighted against the risks.”
Women who do choose to remain on estrogen therapy should have regular mammograms.
These results suggest that current guidelines on hormone replacement therapy are appropriate, according to Jennifer Wu of the Lenox Hill Hospital (NY, USA). “Current guidelines for estrogen therapy hold true,” she stated. “The current recommendation for estrogen therapy is to use the lowest effective dose for the shortest duration of time.”
Source: Chen WY, Manson JE, Hankinson SE et al.: Unopposed estrogen therapy and the risk of invasive breast cancer. Arch. Intern. Med. 166(9), 1027–1032 (2006).
Female-specific knee replacement launched
A knee replacement implant designed especially for women has been approved by the US FDA and will soon be in use across the USA.
Knee replacement implants are already available in different sizes but this is the first to be tailored to the slightly different shape of women's knees.
“Mounting research indicates that a woman's knee is not simply a smaller version of a man's knee. The differences involve the bones, ligaments and tendons in the joints,” explains Aaron Rosenberg, one of the developer surgeons. “Women can wear men's clothing and shoes, but most prefer clothing and shoes made for them. It's the same with knees, and it makes perfect sense to design knee implants with women in mind, particularly considering that women are by far the majority of the knee-replacement patient population.”
Source: Miller KK, Biller BM, Beauregard C et al.: Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study. J. Clin. Endocrinol. Metab. 91(5), 1683–1690 (2006).
Trial of personalized breast cancer treatment launched
The US National Cancer Institute has launched a trial of a genetic profiling system that aims to predict whether a woman will benefit from chemotherapy after surgery to remove a breast tumor.
The trial, known as the Trial Assigning IndividuaLized Options for Treatment (TAILORx), will examine women with hormone receptor-positive, lymph node-negative patients, who make up more than half of breast cancer diagnoses in the USA. These patients are generally treated by surgery and sometimes radiation to remove the tumor, followed by chemotherapy and long-term hormonal therapy. However, it is thought that many women may endure the unpleasant and sometimes dangerous side effects of chemotherapy without gaining any survival advantage.
Developed by Genomic Health Inc. (CA, USA), the genetic screens have been used to estimate that 29% of patients are unlikely to suffer a recurrence and are unlikely to benefit from chemotherapy, whereas 27% are at a high risk and may benefit from chemotherapy. However, this study, involving 100,000 women from 900 clinical centres in the USA, should clarify the outcomes of the 44% of women between these two extremes.
Source: National Cancer Institute Press Release:
www.cancer.gov.
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