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

Mr Ibrahim Bolaji, MD, FRCPI, FRCOG. Consultant Obstetrician and Gynaecologist, Diana Princess of Wales Hospital, Grimsby, DN3 2BA
Honorary Senior Clinical lecturer, Section of Reproductive and Developmental Medicine, University of Sheffield.

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.

Improving consent with technology
The paper from Queens�s Medical centre by Mason 1 hypothesised that providing additional information by video in addition to the standard consultation in women requesting sterilisation increases patients' knowledge about the procedure with no change in anxiety levels in a randomised control trial (N=31). 
The study is a comparison of providing additional information by video in addition to the standard consultation with the standard consultation. This showed that women receiving video information as well as the standard consultation had significantly higher knowledge scores compared with women only receiving the conventional consultation. Women undergoing a conventional consultation (no video) in a nurse-led dedicated sterilisation clinic had significantly higher knowledge scores than women having their consultation in a general gynaecological clinic. There were no differences in anxiety levels between the groups. Information given by video was acceptable to the majority of women. 
1 Mason V, McEwan A, Walker D, Barrett S and James D. The use of video information in obtaining consent for female sterilisation: a randomised study. International Journal of Obstetrics and Gynaecology Volume 110, Issue 12 , December 2003, Pages 1062-1071.

The effect of mobile phone on electronic fetal monitoring
Celik O and Hascalik S1 studied the effects of electromagnetic fields produced by cellular phones (CP) on baseline fetal heart rate, acceleration and deceleration. Forty pregnant women undergoing non-stress test were admitted to the study. Non-stress test was obtained while the subjects were holding the CP on stand by mode and on dialling mode, each for 5 min. Similar recordings were taken while there were no phones around for 10 min. Electromagnetic fields produced by cellular phones do not cause any demonstrable affect in fetal heart rate, acceleration and deceleration. 
1 Onder Celik, and Seyma Hascalik. Effect of electromagnetic field emitted by cellular phones on fetal heart rate patterns. European Journal of Obstetrics & Gynaecology and Reproductive Biology. Volume 112, Issue 1, 15 January 2004, Pages 55-56.

What is the relationship between size and location of uterine fibroids to menstrual loss?
In order to investigate any potential effect of fibroid size and distribution on menstrual blood loss (MBL), Sulaiman et al 1, studied 50 women with symptomatic fibroids who underwent uterine imaging of MRI and objective MBL measurement (using alkaline haematin technique) prior to uterine artery embolisation between 1999 and 2002. 
In this retrospective comparative trial in Scotland, thirty-three (66%) women had objective menorrhagia with a MBL in excess of 80 ml per period. The commonest location of fibroids was intramural; these particular fibroids also had the largest diameter and the greatest uterine volume. There was a negative relationship between MBL and the diameter of the largest fibroid (r=_0.419, P<0.01). All but two women (both of whom had subserosal fibroids alone) demonstrated distortion of the uterine cavity. All women with submucosal fibroids presented with menorrhagia.
This study found that MBL correlated with neither fibroid size nor location. However, all the women with sub-mucosal fibroids had menorrhagia with a MBL greater than 80 ml.

1 Sulaiman S, Khaund A, McMillan N, Moss J, and Lumsden M. Uterine fibroids�do size and location determine menstrual blood loss. European Journal of Obstetrics & Gynaecology and Reproductive Biology Volume 115, Issue 1 , 15 July 2004, Pages 85-89.

Serum CA-125 antigen level and cancer related symptoms in ovarian malignancy
The clinical utility of the serum CA-125 antigen level in demonstrating objective evidence of regression or progression of disease in women with ovarian cancer is well established. However, the relationship between both the absolute value of this tumour marker, or its rate of change over time, and the short-term clinical course (e.g., development of cancer-related symptoms) in individual patients remains poorly defined. 
Maurie Markman and his group 1 studied five women under the care of physicians in the Gynecologic Cancer program of the Cleveland Clinic. They demonstrated the marked variability in the correlation between the serum CA-125 antigen and the natural history of disease for individual patients with ovarian or primary peritoneal cancers. In these cases, persistent elevations (>100 units/ml for >2 years), rapid changes (<200 units/ml to >2000 units/ml over �2 months), or extremely high CA-125 values (>5000 units/ml) failed to accurately predict the presence, time to development, or severity of symptoms. 
It was concluded that in the second-line and palliative management of ovarian or primary peritoneal cancers, it is important to emphasize the critical need for clinical judgment in the decision to initiate or alter therapy in individual patients based solely on changes in the serum level of the CA-125 antigen. 
1 Markman M , Webster K, Zanotti K, Peterson G, Kulp B and Belinson J. Examples of the marked variability in the relationship between the serum CA-125 antigen level and cancer-related symptoms in ovarian cancer. Gynecologic Oncology Volume 93, Issue 3 , June 2004, Pages 715-717.

Alternative to second generation endometrial ablation method
In a prospective trial to assess the efficacy of topically applied trichloroacetic acid (TCA) for endometrial ablation in patients with dysfunctional uterine bleeding (DUB), the Turkish group1 studied 90 patients.
The patients were allocated into three treatment groups of 30. In group I, patients underwent dilatation and curettage before endometrial ablation. In group II patients were administered danazol before ablation. Patients in group III received goserelin acetate on the same day and 28 days after ablation. Endometrium was evaluated by biopsy, transvaginal ultrasonography and hysteroscopy. Endometrial ablation was performed in 95% with TCA. All of the patients were evaluated 3 and 6 months after TCA application. 
After 6 months of treatment, the success rate was recorded as 83% in the first group, 92.3% in the second group and 96.6% in the third group. The mean length of uterine cavity was reduced in all groups, being only significant in Goserelin group (P<0.5). Endometrial thickness was decreased significantly in all treatment groups (P<0.001). 
This study concluded that endometrial ablation by TCA may readily be performed as an alternative treatment method in the management of DUB. Moreover, suppression of endometrium with danazol or especially with goserelin acetate before ablation resulted in significant success rate.
1 Kucukozkan T, Kadioglu BG, Uygur D, Moroy P, Mollamahmutoglu L and Besli M. Chemical ablation of endometrium with trichloroacetic acid. International Journal of Gynaecology and Obstetrics Volume 84, Issue 1 , January 2004, Pages 41-46.

The role of outpatient alcohol sclerotherapy and aspiration in the management of Bartholins abscess or cyst.
In a comparative prospective study by Kafali et al 1, the efficiency and safety of alcohol sclerotherapy of Bartholin�s cyst or abscess was compared with silver nitrate insertion. 
Twenty-two patients with unilateral Bartholin�s cyst or abscess were randomized into one of the treatment groups according to diameter of cyst or abscess. Group I consisted of 12 patients who were treated with alcohol sclerotherapy and Group II included 10 patients who were treated with silver nitrate insertion. In both groups, treatments were conducted under local anaesthesia and in an outpatient setting. The patients were checked for morbidity of operations every 3 days until complete healing was observed and then followed up monthly for over 24 months. 
The mean duration of procedure was 7�2 min in group I and 15�3 min in group II. Healing time was 4.8�1.3 days in group I and 9.2�2.5 days in group II. In group I although 10 patients showed complete healing without any early or late morbidity; two patients suffered from severe vulval pain, oedema and echymosis, and then developed a total cyst necrosis. Healing in these patients were completed with mild scar formation. Only one recurrence was documented during 24 months follow-up period. All patients in group II complained of labial pain, four of them suffered from severe labial pain, oedema, and echymosis. Healing in these patients was completed with moderate scar formation. Follow-up of 24 months revealed no recurrence in this group
In conclusion, alcohol sclerotherapy of Bartholin�s cyst or abscess is as effective as silver nitrate application and is associated with less complication. It may be ideal, safe and attractive treatment modality for this gynaecological disease. 
1 Hasan Kafali, Seniz Yurtseven and Ilyas Ozardali. Aspiration and alcohol sclerotherapy: a novel method for management of Bartholin�s cyst or abscess. European Journal of Obstetrics & Gynecology and Reproductive Biology Volume 112, Issue 1 , 15 January 2004, Pages 98-101.

Intimate Partner Violence (IPV)
Kramer et al 1 from Wincousin USA revisit the issue of intimate partner violence (IPV) and her findings are easily adaptable to situation in the UK. The aim of their study was to determine: the prevalence of IPV among women accessing health care, factors that influence rates of abuse, barriers to disclosure, associated health problems and perceptions of safety. 
Of women in this study (n=1268 anonymous questionnaires), 50�57% had experienced physical and/or emotional abuse and 26% reported sexual abuse in their lifetime. In the past year, 28% reported emotional abuse, 12% physical abuse, 6% severe physical abuse, and 4% sexual abuse. Logistic regression models found that younger, less educated, less-affluent women presenting to urban Emergency Departments reported the highest rates of physical abuse. Although 83% welcomed abuse screening, only 25% ever had been asked and 86% would disclose abuse if asked directly, respectfully, and confidentially. Abused women reported significantly lower health status ratings than non-abused women (p < 0.001). Emotional abuse was as strongly associated with health problems as physical abuse. The majority (70�93%) of women with headaches, stomach problems, chronic pain, vaginal bleeding, substance abuse, depression, and suicidal thoughts had experienced lifetime physical/emotional abuse. 
They concluded that women experience many forms of abuse and present to a wide range of health care settings. The striking prevalence of IPV and associated emotional/physical health problems challenges providers to routinely assess for abuse in ways that minimize barriers to disclosure and enhance the development of an effective plan of care based on a patient's abuse experience.
1 Kramer A, Lorenzon D and Mueller G . Prevalence of intimate partner violence and health implications for women using emergency departments and primary care clinics. Women�s Health Issues Volume 14, Issue 1 , January-February 2004, Pages 19-29 .

Is there still a place for routine antenatal screening for syphilis?
Kiss et al 1 in a retrospective 10-year study, analysed the effectiveness of the current antenatal syphilis screening in Austria.
The diagnosis of syphilis in Austria and Vienna was determined based on the data published by the Austrian Bureau of National Statistics (Statistik Austria) and the Vienna Health Authority respectively. The data obtained for Vienna were then compared with those for the remaining eight federal provinces. Also, they retrospectively analysed a total of 34,312 sera obtained between 1988 and 1999 from women screened for syphilis at delivery at the University of Vienna. Serological screening was done with both the Veneral Disease Research Laboratory (VDRL) and the Treponema pallidum haemagglutination (TPHA) assays. Finally, they determined the number of cases of congenital syphilis diagnosed in Vienna between 1988 and 1999. 
In the past 10 years, the annual number of reported syphilis cases had remained fairly constant. In 1999 and 2000, there were 8.1 and 11.0 notifications of syphilis per 100,000 inhabitants in the capital Vienna, compared with 0.7 and 0.9 in the remaining provinces with a mainly rural character. At delivery, there were 96 cases of maternal syphilis that were both TPHA- and fluorescent treponaemal absorption (FTA-ABS)-reactive, corresponding to a seroprevalence of 2.8 per 1000 births. Only 24 of the TPHA-reactive sera were VDRL-reactive. In Vienna, there were three stillbirth deliveries due to congenital syphilis and six cases of confirmed congenital syphilis between 1988 and 1999.
It was concluded that universal syphilis screening may no longer be justified economically. The usefulness of VDRL-based syphilis screening should be reassessed and the screening focus should shift to regions with a high seroprevalence of syphilis.
1 Kiss H, Widhalm A, Geusau A, Husslein P. Universal antenatal screening for syphilsis: is it still justified economically? European Journal of Obstetrics & Gynaecology and Reproductive Biology Volume 112, Issue 1 , 15 January 2004, Pages 24-28.

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