SEARCHLIGHT Navigating the Global Medical Network Of Sexual Health Issues for Sexual Health Matters

You are welcome to this column in Sexual Health Matters that will regularly navigate the medical world to flag recent development in Sexual Health issues. There will be opportunity to take part in regular problem based searchlight medical exercises. The columnist welcomes regular feedback from readers through the feed back e-mail. Enjoy your reading.

Gynaecologists and General Practitioners may be failing to pick up cases of sex abuse amongst their patients.
A short anonymous questionnaire survey 1 to estimate the prevalence of sexual abuse among patients was distributed to 1157 women attending a gynaecological outpatient clinic at a large urban teaching hospital in Germany. Data collected using the questionnaire included patient characteristics, sexual abuse history, and screening practices. Women who reported that they had been abused were asked if they had ever discussed the issue with their gynaecologist. A total of 1075 questionnaires were returned, for a response rate of 92.9%. Almost half (n = 479 [44.6%]) of the women surveyed reported that they had been the subject of unwanted sexual attention by different relationship table 1. One fifth (n = 216 [20.1%]) had been forced to engage in sexual activities: 6.8% in childhood, 10.3% during adolescence, 6.4% as adults, and 3.5% across more than one stage. Thirteen women (6%) reported having discussed the abuse with their gynaecologist. Sixty-six (30.5%) were too afraid to raise the issue, and 119 (55.1%) stated it was not relevant to their care. Only one woman (0.5%) reported that her gynaecologist had asked about sexual abuse.

Table 1. Women Forced Into Sexual Activities by Relationship to Offender 
*Because some women were forced to engage in unwanted sexual activities by more than one offender, percentages total more than 100.

Despite the high prevalence of sexual abuse among women seeking gynaecologic care, routine screening does not appear to be part of standardized practice. Gynaecologists should include sexual and sex abuse history into their history-examination-investigation diagnostic triad. 
1Peschers M.U , Du Mont J, Jundt K, Pf ürtner M, Dugan E and Kindermann G. Prevalence of sexual abuse among women seeking gynaecologic care in Germany. Obstetrics & Gynaecology 2003: Vol.101(1) ;103-108 .

Endometriosis may predispose to ovarian cancer.
A recent review by Ness 1 from Pittsburgh Cancer Institute in the American Journal of Obstetrics and gynaecology reviews the English language literature for in vitro, animal, clinical, and epidemiologic studies linking endometriosis and ovarian cancer in order to find the explanation for the linkage.
He found that pathology case series consistently report endometrioid and clear cell types of ovarian cancer arising from endometriotic foci. Epidemiologic studies have been consistent with this association. There are also marked similarities between the proposed aetiology of ovarian cancer and the observed pathophysiology of endometriosis. Specifically, both are characterized by immune alterations. Both conditions are promoted by oestrogen excess and by progesterone deficit. Finally, steroid hormones interacting with the immune system may stimulate both endometriosis and ovarian cancer.
In this article he proposes that the biology common to endometriosis and ovarian cancer represents a causal pathway: aberrant immune function, fed by and feeding on estrogens, unbalanced by progesterone, may create a positive feed-forward loop that enhances the growth and invasiveness of endometriosis and promotes its malignant transformation.
He concluded that the same pathophysiology may orchestrate the progression of endometriosis and its transformation to endometroid and clear cell ovarian neoplasia. This notion of a unifying biology suggests a directed approach to future research and identifies possible chemoprevention strategies for women with endometriosis. 
1 Roberta B. Ness. Endometriosis and ovarian cancer: Thoughts on shared pathophysiology. Am J Obstet Gynaecol 2003; 189:280-94.

Bacterial Vaginosis is a risk factor for Preterm Labour.
A meta-analysis of original English-language reports of prospective studies or control groups of clinical trials 1 involving women at <37 weeks gestation with unruptured membranes, clinical or Gram-staining diagnosis of Bacterial Vaginosis (BV) and the outcomes of preterm delivery, spontaneous miscarriage, maternal or neonatal infection, and perinatal death was performed. Eighteen studies involving 20,232 patients were included.
Bacterial vaginosis increased the risk of preterm delivery >2-fold (odds ratio, 2.19; 95% CI, 1.54-3.12). Higher risks were calculated for subgroups of studies that were screened for BV at <16 weeks of gestation (odds ratio, 7.55; 95% CI, 1.80-31.65) or at <20 weeks of gestation (odds ratio, 4.20; 95% CI, 2.11-8.39). BV also significantly increased the risk of spontaneous abortion (odds ratio, 9.91; 95% CI, 1.99-49.34) and maternal infection (odds ratio, 2.53; 95% CI, 1.26-5.08). No significant results were calculated for the outcome of neonatal infection or perinatal death. 
This study showed that BV, early in pregnancy, is a strong risk factor for preterm delivery and spontaneous abortion.
1 Harald Leitich H, Bodner-Adler B, Brunbauer M, Kaider A, Egarter C and Husslein P. Bacterial vaginosis as a risk factor for preterm delivery: A meta-analysis. Am J Obstet Gynaecol 2003;189:139-47. 

The Million Women Study-WMS
It has been established from three reliable sources, The Nurses’ study 1, Collaborative Group on Hormonal factors in breast 2 and more recently the WHI (The Women’s Health Initiative) study 3, that postmenopausal hormone replacement therapy (HRT) is associated with a slightly increased breast cancer risk after at least 5 years’ exposure. All these studies consistently found that HRT of 5 years or longer slightly increased breast cancer risk, per 1000 women with 2 extra cases after 5 years, 6 extra cases after 10 years and 12 extra cases after 15 years of use with no increase in mortality due to breast cancer.
The Million Women Study (MWS)4 published in Lancet on August 9, 2003 added a new dimension. It is a retrospective cohort study involving just over 1 million British women aged 50-64 years who participated in the National Breast Cancer Screening Programme.
In this study 9364 breast cancers were diagnosed and 637 patients died due to this disease. Relative risks for incident breast cancer were increased for unopposed oestrogen, combined oestrogen and progestogen and tibolone. Risk increases were observed after just one year of exposure, and had almost disappeared 12 months after discontinuation of HRT. In addition breast cancer mortality risk was increased.

1. Colditz GA, Hankinson SE, Hunter DJ et al.New Eng J.Med 1995; 332:1589-1593.
2 Collaborative Group on Hormonal factors in Breast Cancer. Lancet 1997;350:1047-1059.
3. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321–33.
4. Birkhauser M, Roura C.,Erkkola R, Genazzani A. Million Women Study Collaborators. Lancet 2003; 362: 419-427

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