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GPs with an interest in women's health review the latest papers of significance from research teams across the world.

Cardiovascular mortality after early bilateral oophorectomy
Rivera CM, Grossardt BR, Rhodes DJ et al. Menopause 2009; 16(1): 15-23
Early ovarian failure increases mortality and cardiovascular disease (CVD). This US study looked at the effect of oophorectomy and HRT on CVD mortality in 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy and 2,383 controls. They found that women who underwent unilateral oophorectomy experienced a reduced CVD mortality compared with the controls. Women who underwent bilateral oophorectomy before the age of 45 years experienced an increased mortality compared with the controls (HR 1.44, 95% CI 1.01-2.05). Mortality was significantly increased in women not taking estrogen before the age of 45 years or beyond (HR 1.84, 95% CI 1.27-2.68) but not in HRT users. Mortality was further increased after deaths associated with cerebrovascular causes were excluded. Bilateral oophorectomy performed before the age of 45 years is associated with increased cardiovascular, especially cardiac, mortality, and HRT may prevent this.

- Miss Margaret Rees is reader in reproductive medicine, University of Oxford, honorary consultant in medical gynaecology and visiting professor, faculty of medicine, University of Glasgow


Preterm birth and antenatal maternal severe life events
Khashan AS, McNamee R, Abel KM et al. Hum Reprod 2009; 1(1): 1-9
Preterm birth has been linked to maternal stress during pregnancy. The authors investigated the association between maternal exposure to severe life events and risk of preterm birth in 1.35 million mothers with singleton pregnancies in Denmark between 1 January 1979 and 31 December 2002.

Exposure was defined as death or serious illness in close relatives in the first or second trimesters or in the six months before conception. There were 58,626 (4.34 per cent) preterm births (<37 weeks), 11,732 (0.87 per cent) very preterm births and 3,288 (0.24 per cent) extremely preterm births.

Severe life events in close relatives in the six months before conception increased the risk of preterm birth by 16 per cent (RR = 1.16, 95% CI 1.08-1.23). Severe life events in older children in the six months before conception increased the risk of preterm birth by 23 per cent (RR = 1.23, 95% CI 1.02-1.49) and the risk of very preterm birth by 59 per cent (RR = 1.59, 95% CI 1.08-2.35). This study suggests that severe life events, particularly in the six months before pregnancy, may increase the risk of preterm and very preterm birth and women should probably avoid conceiving in these circumstances. MR


Post-MI sex differences in medical care and early death
Jneid H, Fonarow GC, Cannon CP et al, for the Get With the Guidelines Steering Committee and Investigators. Circulation 2008; 118(25): 2803-10

It is of concern that there are gender differences in care after acute MI. The authors used the Get With the Guidelines - Coronary Artery Disease database to examine gender differences in management and in-hospital death among 78,254 patients with acute MI in 420 US hospitals from 2001 to 2006.

Women were older, had more comorbidities, presented less often with ST-elevation MI (STEMI) and had higher unadjusted in-hospital death (8.2 per cent v 5.7 per cent) than men. However, after adjustment, gender differences in in-hospital mortality rates were no longer observed in the overall cohort, but persisted among STEMI patients (10.2 per cent v 5.5 per cent).

Compared with men, women were less likely to receive early aspirin or beta-blocker treatment, reperfusion therapy or timely reperfusion (door to needle time ≤30 minutes; door to balloon time ≤90 minutes). Women also had lower use of cardiac catheterisation and revascularisation. Thus evidence-based treatments are still underused or delayed, despite increasing awareness of CHD as a leading cause of death in women. MR


Elective repeat caesarean and neonatal outcomes
Tita ATN, Landon MB, Spong CY et al for the Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. N Engl J Med 2009; 360: 111-20
If your patients require an elective caesarean section, the safest time as regards neonatal outcome is 39 weeks, not before.

A cohort of 24,077 repeat caesarean deliveries at term were analysed from the US, of which 13,258 were planned electives. Of these, more than one-third (35.8 per cent) were carried out before 39 weeks' gestation, and about half (49.1 per cent) at 39 weeks. The adverse neonatal events, including respiratory complications, treated hypoglycaemia, newborn sepsis and admission to the neonatal intensive care unit, were then compared by age at gestation. The risks of these adverse events were increased by a factor of 1.8-4.2 at 37 weeks compared with 39 weeks, and increased by a factor of 1.3-2.1 at 38 weeks.

It is always difficult to judge lung maturity, but this paper strongly adds to the opinion that for an elective caesarean in a well mother and a flourishing fetus, 39 weeks is best and an earlier date should not be risked. At present, a large number of babies are being put at unnecessarily increased risk by obstetricians opting for a slightly earlier elective caesarean delivery. This will also be using more paediatric neonatal resources in an already overstretched area of ITU cots, which is a potent economic argument to opt for 39 weeks' gestation for repeat elective caesareans in well mothers and babies.

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


Psychological interventions in premenstrual syndrome
Busse JW, Montori VM, Krasnik C et al. Psychother Psychosom 2009; 78: 6-15
A team of researchers in Canada has conducted a systematic review and meta-analysis to determine the efficacy of carrying out psychological interventions for women who have premenstrual syndrome.

They selected studies that had enrolled women with premenstrual syndrome and randomly assigned them to a psychological intervention or a control intervention. Trials were included irrespective of outcome and meta-analyses were conducted where possible.

Nine randomised trials, of which five investigated cognitive behavioural therapy, contributed data to the meta-analyses. The researchers found the evidence to be of low quality, with study design and implementation weaknesses and possible reporting bias. However, there were positive suggestions, in that cognitive behavioural therapy appeared to reduce anxiety significantly (number needed to treat [NNT] = 5) and depression (NNT = 5), and also had a possible beneficial effect on behavioural changes (NNT = 4) and interference of symptoms on daily living (NNT = 4).

Support for monitoring as a form of therapy was much more limited, while education appeared to be ineffective. The researchers conclude that cognitive behavioural therapy may have important beneficial effects in managing symptoms associated with premenstrual syndrome. SH


Maternity leave and failure to establish breastfeeding
Guendelman S, Kosa JL, Pearl M et al. Pediatrics 2009; 123(1): e38-e46 (doi:10.1542/peds.2008-2244)
In the UK, it is rare for women to have less than six weeks of maternity leave, but this is not the case for all women.

I used to provide antenatal care for American women who worked on the US airbase in Oxfordshire. They had to be back on active service within six weeks of childbirth or they would lose their job. Most British mothers have scarcely managed to dress and go round the supermarket once by the six weeks postnatal check, and have hopefully established breastfeeding.

In a study from California, it did not surprise me to read that maternity leave of six weeks or less was associated with a fourfold greater risk of failing to establish breastfeeding: the breast milk had barely come in before you were expected to be back behind a computer. What shocked me was the fact that California is one of only five US states to provide paid pregnancy leave 'to extend for infant bonding'.

The federal leave programme allows 12 weeks of unpaid job-protected leave during pregnancy or after childbirth. The law excludes companies with fewer than 50 employees, part-time employees, and those working in informal labour markets. Many non-affluent workers do not take leave because they cannot forgo pay, or are not covered.

Postpartum leave of six to 12 weeks carried a twofold risk of failure to breastfeed. As would be expected, breastfeeding was lower in women who were doing inflexible and non-managerial jobs, of lower educational attainment, young age and single, just as in the UK. This study concluded that delaying return to work by at least three months is positively associated with breastfeeding duration. In the US, 72 per cent of women start to breastfeed, but by six months this has dropped to 35 per cent. In this study, it was 82 per cent who established breastfeeding.

The US does not have the system of community midwives and health visitors that there is in the UK, which would explain the high failure rate in the US study in the first month, because women in the US do not have such support. This study made me realise what a tough time women there have postnatally. SH


Patient and doctor gender in the treatment of heart failure
Baumhakel M, Muller U, Bohm M. Eur J Heart Fail 2009; doi:10.1093/eurjhf/hfn041

Several recent studies have found gender differences in the medical care and survival of patients with cardiovascular disease; in general, women appear to be treated less intensively than men. This study, undertaken in Germany, paints a similar picture. However, it shows that not only does the extent to which evidence-based treatment is employed in chronic heart failure (CHF) depend on the gender of the patient, it also depends on the gender of the treating physician.

The study involved 1,857 patients with CHF, who were evaluated in terms of comorbidities, New York Heart Association classification, current medical treatment and specifically, dosages of ACE inhibitors and beta-blockers being taken. Treatment was compared with best practice, as outlined in European Society of Cardiology guidelines for heart failure.

The gender of patients and treating physicians was also recorded. In total, 829 physicians (65 per cent were GPs, 27 per cent internists and 7 per cent cardiologists) were involved.

Overall, the results showed that female patients were less often treated with ACE inhibitors, angiotensin-receptor blockers or beta-blockers. Furthermore, achieved doses were lower in female than in male patients.

There was no difference in the treatment of male or female patients by female physicians, and guideline-recommended drug use and achieved target doses tended to be higher in patients being treated by female physicians. Notably, male physicians used significantly less medication and lower doses in female patients.

The dosage of beta-blockers was comparable in male patients irrespective of the physician's gender; female patients treated by a male physician received the lowest doses. Multivariable analysis showed that female gender of the treating physician was an independent predictor of beta-blocker use.

The researchers conclude that male patients with CHF are more likely to receive evidence-based drug treatment than female patients, particularly in relation to ACE inhibitors and beta-blockers. They stress that clinicians need to be aware of this problem to avoid such gender-related treatment imbalances.

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