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Experts with an interest in women’s health review papers of significance from research teams across the world

Bone mass in premenopausal women with depression
Postmenopausal bleeding and the thin endometrium
Tea consumption and carotid plaques in women
A new test for chlamydia
Setting up a control group to study epilepsy in pregnancy
The prevalence of HPV in HIV-infected women
Safe exercise in pregnancy
Elective caesarean delivery

Bone mass in premenopausal women with depression
Eskandari F, Martinez PE, Torvik S et al for the Premenopausal, Osteoporosis Women, Alendronate, Depression (POWER) Study Group. Arch Intern Med 2007; 167: 2329-36

An increased prevalence of low bone mineral density (BMD) has been reported in patients with major depressive disorder, mostly women. Eighty-nine premenopausal women with major depressive disorder and 44 healthy control women were studied.

The prevalence of low BMD, defined as a T score <-1, was greater in women with major depressive disorder versus controls at the femoral neck (17 v 2 per cent; p = 0.02) and total hip (15 v 2 per cent; p = 0.03) and tended to be greater at the lumbar spine (20 v 9 per cent; p = 0.14). These findings need to be confirmed in larger studies, but are of concern because osteoporosis affects one in three women. Use of SSRIs is also associated with an increased rate of bone loss at the hip in older women.1

- Miss Margaret Rees is reader in reproductive medicine and honorary consultant in medical gynaecology at John Radcliffe Hospital, Oxford

Reference: 1. Diem SJ, Blackwell TL, Stone KL et al. Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Arch Intern Med 2007; 167: 1240-5.

Postmenopausal bleeding and the thin endometrium
Van Doorn HC, Timmermans A, Opmeer BC et al. Acta Obstet Gynecol Scand 2008; 87: 89-93

Reinvestigation of recurrent postmenopausal bleeding (PMB) in women with initially normal findings is a common clinical problem. This study followed up 249 women with an initial episode of PMB who were not on HRT and had an endometrial thickness m4mm. Median duration of follow-up was 174 weeks (range: 4–250 weeks).

During that time, 25 of the 249 patients (10 per cent; 95 per cent CI 6.6–14 per cent) had recurrent bleeding. Median time until recurrence of bleeding was 49 weeks (range: 9–186 weeks). Two patients with recurrent bleeding had an endometrial carcinoma (8 per cent; 95 per cent CI 2.2–25 per cent), and one had a malignant melanoma. Time since menopause, age, BMI, hypertension, diabetes and anticoagulants were not predictive of recurrent bleeding.

Women with PMB should be re-evaluated urgently because they are at increased risk of malignancy and should be referred to secondary care via the two-week wait system. MR

Tea consumption and carotid plaques in women
Debette S, Courbon D, Leone N et al. Arterioscler Thromb Vasc Biol Dec 2007; doi:10.1161/ATVBAHA.107.158634

Tea (Camellia sinensis) is one of the mostly widely consumed non-alcoholic beverages. Its cultivation dates back millennia to eastern Asia, where it was used for medicinal purposes.

This study examined the health benefits of tea in two populations in France. The first (Three-City study) examined 3,984 women and 2,613 men aged 65 years or more. Atherosclerotic plaques in the extracranial carotid arteries and carotid artery intima-media thickness (CCA-IMT) were measured. Increasing daily tea consumption was associated with a lower prevalence of carotid plaques: 44.0 per cent, 42.5 per cent and 33.7 per cent in women drinking no tea, one to two cups per day and three or more cups per day (p = 0.0001).

This association was independent of age, study centre, major vascular risk factors, educational level and dietary habits. There was no association of tea consumption with carotid plaques in men, or CCA-IMT in both genders.

The second study (EVA-Study) involved 661 women. Here, carotid plaque frequency was 18.8 per cent, 18.5 per cent and 8.9 per cent in women drinking no tea, one to two cups per day and three or more cups per day (p = 0.08). Drinking tea appears to have health benefits and may reduce the risk of cardiovascular disease in elderly women. MR

A new test for chlamydia
Mahilum-Tapay L, Laitila V, Wawrzyniak JJ et al. BMJ 2007; 335: 1190-4

This article describes the evaluation of a test for Chlamydia trachomatis, designed to be used for diagnosis and screening on samples obtained from vaginal swabs. Its major advantage is that the results are available in 30 minutes.

The study was carried out in three centres in the UK – two GUM clinics and one young people’s sexual health clinic – recruiting 1,349 female patients. The ojective was to evaluate sensitivity, specificity, positive and negative predictive value and patient acceptability of the rapid test.

Samples were obtained by a mixture of physician-collected and patient-collected swabs, and urine testing, and results from the rapid test were compared with those from standard chlamydia diagnostic techniques.

The conclusion was that self-collected swabs were acceptable to women and diagnostically accurate. This is excellent news because it will allow patients to be diagnosed and treated in the same visit to a GUM clinic.

- Dr Alison Glenesk is a GP with a special interest in women’s health in Aberdeen, Scotland

Setting up a control group to study epilepsy in pregnancy
Vajdaa FJ, O’Brien T, Hitchcock A et al. J Clin Neurosci 2008; 15: 29-35

This paper describes the setting up and validation of a control group of untreated epileptic women for inclusion in a study to investigate the rate of foetal abnormality in a group of treated epileptic pregnancies.

The authors describe difficulties with control groups in previous studies. Often, the general population is used, but there may be important socio-economic and other differences between epileptic and non-epileptic groups.

In 1999, an Australia-wide register was set up to record data on the outcome of pregnancy in epileptic women. The control group was required for an attempt to analyse these data. By May 2005, there were 777 completed pregnancies, 68 of which had not been exposed to antiepileptic medication, at least until week 13. Some had not taken medication for several months before pregnancy and some appeared to have stopped their medication in preparation for pregnancy.

This group was compared with the 709 drug-treated patients using more than 50 parameters, including personal data, past and present obstetric data, folic acid intake, smoking and characteristics of their epilepsy. It was found that statistically significant differences existed for only seven parameters, none of which would affect the rate of foetal malformation.

It was concluded, therefore, that the untreated patients formed a valid control group. This study was interesting, although conceptually different from most others because it describes the statistical preparation required in the planning stage of a clinical trial. I am now looking out for the actual results. AG

The prevalence of HPV in HIV-infected women
Jong E, Mulder JW, van Gorp EC et al. J Clin Virol 2007 doi: 10.1016/j.jcv.2007.10.007

Women who have been diagnosed with HIV are five times more likely to have cervical squamous intraepithelial lesions (SILs) than uninfected women. Furthermore, SILs in HIV-positive women progress more rapidly.

HIV-positive women are advised to have six-monthly smears in the first year and yearly smears thereafter if the results are normal, but the real problem is low concordance with cervical screening, presumably because these women are worrying about HIV and not about HPV.

Persistent infection with oncogenic HPV types 16, 18, 31, 33 and 45 is associated with developing cervical cancer. These can now be detected with a urine sample using viral nucleic acid isolation kits. Urine can also be screened for other STIs, such as chlamydia and Neisseria gonorrhoeae. In this small study, paired urine and cervical smears (using liquid based cytology) were obtained from 27 HIV-infected women. The technique looked at 25 different HPV types, including all the oncogenic ones.

The concordance between the urine and cervical smear samples for HPV positivity or negativity was 71 per cent. As the grading of the dysplasia increased in severity, so did the concordance. So in the 25.9 per cent of women in this sample who had an abnormal cervical smear, 100 per cent had HPV-positive urine samples. The authors conclude that this would be a useful screening test for HIV-positive women.

- Dr Sally Hope is a GP in Woodstock, Oxfordshire, and honorary research fellow in women’s health, department of primary health care, University of Oxford

Safe exercise in pregnancy
Duncombe D, Wertheim E, Skouteris H et al. Midwifery (article in press) doi: 10.1016/j.midw.2007.03.002

How much exercise is safe or advisable during pregnancy? The American College of Obstetricians and Gynecologists used to recommend that sedentary women should avoid ‘vigorous exercise’ in pregnancy. Its guidelines were revised in 2002 to acknowledge that exercise was beneficial in pregnancy, and recommended 30 minutes of ‘moderate exercise’ on ‘most, if not all, days’, bearing in mind individual circumstances.

This study from Melbourne assessed women’s beliefs about exercise in pregnancy and asked them to keep a diary of their activities. It showed that 77.2 per cent of pregnant women thought low-intensity exercise (walking, gentle swimming) was very safe, whereas none of them felt that high-impact exercise was safe during pregnancy. The researchers recommend that health professionals should discuss the benefits of continuing safe exercise throughout pregnancy. SH

Elective caesarean delivery
Villar J, Vallandares E, Wojdyla D et al. Lancet 2006; 367: 572-7

This paper provides data from the WHO 2005 global survey on maternal and perinatal health, looking at 106,546 deliveries over three months in eight Latin American countries. Elective caesarean section has increased worldwide in the past 20 years; this paper assesses the potential risks and benefits.

Women who had a vaginal delivery were more likely to be poorly educated, single, young and primiparous, while the elective caesarean group had a high risk of previous complicated pregnancies or perinatal outcomes and problems related to the current pregnancy, such as eclampsia.

The maternal morbidity and mortality index in the elective caesarean group (5.5 per cent) was higher than in the vaginal group (1.8 per cent). The OR for antibiotic treatment after delivery was four to five times higher in the caesarean group. A caesarean delivery had a protective effect on the development of a postpartum fistula. In cephalic presentations, adjusting for confounding variables and gestational age, there was a doubling of risk of admission to neonatal intensive care for seven or more days afterwards, whereas breech presentation undergoing caesarean was associated with a lower neonatal mortality, regardless of gestational age.

This paper suggests that elective caesarean as a ‘cultural demand’ is independently associated with increased maternal and neonatal morbidity and mortality in Latin America. SH

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